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Based on interview, record review, video review and policy review, the hospital failed to ensure within its capability and capacity, ongoing assessment and reassessment of a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) and failed to provide a safe transfer for one patient (#17) of 30 Emergency Department (ED) records reviewed from 10/01/23 through 04/01/24. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) - Screening, Stabilization and Transfer Policy," dated 04/2023, showed:
- The hospital will provide an appropriate MSE for individuals who come to the ED to determine whether or not an EMC exists.
- If an EMC exists, the hospital will provide any necessary stabilizing treatment within its capabilities or conduct an appropriate transfer of the patient.
- Nursing will assure that the care delivered during transport will be provided by an appropriately trained, certified and/or licensed service that is competent to perform the care and treatment needed by the individual.

Review of the hospital's document titled, "Rules and Regulations," approved 03/27/12, showed all patients presenting seeking care will be provided a MSE.

Although requested, the hospital failed to provide a policy that addressed criteria for discharge by a taxi.

Review of Patient #17's ED medical record, dated 03/13/24, showed:
- She was a 74-year-old female who arrived by ambulance from Facility B (long-term care facility) at 4:46 AM with nausea, vomiting, and diarrhea.
- Intake assessment documented level of consciousness was awake, alert, and appropriate. She was oriented to person, place, time, and situation.
- Lab work showed an elevated white blood cell (WBC, the number of white cells [infection-fighting cells] in the blood) count at 16.12 (normal is 4.5 to 11) and a low hemoglobin (Hgb, a protein in red blood cells that carries oxygen through the body) of 11.7 grams/deciliter (dl, a measurement of liquid) (normal is 12.0 to 16.0).
- A computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) of the abdomen showed liquid content in the colon and rectum indicating diarrhea and nodularity in the lower lobes of the lungs consistent with an atypical infection or aspiration (inhalation of foreign material into the lungs).
- She was given one liter of normal saline (saltwater solution), ondansetron (medication used to treat nausea) four milligrams (mg, unit of dosage strength) and metoclopramide (medication used to treat nausea and vomiting) 10 mg, intravenously (IV, in the vein).
- No vital signs were documented after 12:15 PM.
- The patient was discharged at 1:31 PM by taxi.

Patient #17 was discharged to Facility B at 1:31 PM by taxi and returned by ambulance from Facility B at 2:27 PM, intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own). Patient #17 experienced a code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) and expired at 2:59 PM.

Based on interview, record review, video review and policy review, the hospital failed to provide, within its capability and capacity, ongoing assessment and reassessment of a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#17) of 30 Emergency Department (ED) records reviewed from 10/01/23 through 04/01/24. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Screening, Stabilization and Transfer," dated 04/2023, showed:
- The hospital will provide an appropriate MSE for individuals who come to the ED to determine whether or not an EMC exists.
- If an EMC exists, necessary stabilizing treatment will be provided within its capabilities.
- Nursing will assure that vital signs (body temperature [degree of hotness or coldness of the body, normal is 98.6 °F], blood pressure [BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heart beat, normal is approximately 90/60 to 120/80], heart rate [the number of times the heart beats within a certain time period, usually a minute] and breathing rate) and ongoing assessment documentation during the stay and immediately prior to discharge are complete and sent with the individual.

Review of the hospital's document titled, "Rules and Regulations," approved 03/27/12, showed all patients presenting seeking care will be provided a MSE.

Review of Patient #17's ambulance report, dated 03/13/24, showed:
- She requested to go to the hospital because she had developed difficulty breathing and was having nausea, vomiting, and diarrhea.
- When Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) arrived, her oxygen was set to three liters per minute (L/min), her normal home setting.
- An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed sinus arrhythmia (abnormal heartbeat) with premature ventricular contractions (PVCs, a type of abnormal heartbeat) with a pulse (number of heartbeats per minute) of 94.
- She received ondansetron (medication used to treat nausea) four milligrams (mg, a measure of dosage strength).

Review of Patient #17's medical record, dated 03/13/24, showed:
- She was a 74-year-old female who arrived by ambulance from Facility B (long-term care facility) at 4:46 AM with nausea, vomiting, and diarrhea.
- Intake assessment documented level of consciousness was awake, alert, and appropriate. She was oriented to person, place, time, and situation.
- Lab work showed an elevated white blood cell (WBC, the number of white cells [infection-fighting cells] in the blood) count at 16.12 (normal is 4.5 to 11) and a low hemoglobin (Hgb, a protein in red blood cells that carries oxygen through the body) of 11.7 grams/deciliter (dl, a measurement of liquid) (normal is 12.0 to 16.0).
- A computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) of the abdomen showed liquid content in the colon and rectum indicating diarrhea and nodularity in the lower lobes of the lungs consistent with an atypical infection or aspiration (inhalation of foreign material into the lungs).
- She was given one liter of normal saline (saltwater solution), ondansetron four mg and metoclopramide (medication used to treat nausea and vomiting) 10 mg, intravenously (IV, in the vein).
- At 7:30 AM, she reported no nausea or diarrhea and had the ability to tolerate oral fluids.
- Her pulse rate ranged from 41 to 125, with the last recorded value of 124, at 12:15 PM.
- No vital signs were documented after 12:15 PM.
- The patient was discharged at 1:31 PM by taxi.

Review of the hospital's video labeled 03/13/24 Emergency Room (ER) Nurse Station, showed at 1:34:21 PM, Patient #17 was slumped in a wheelchair with her head down and her chin on her chest. The wheelchair was pushed by Staff O, ED Technician, and Staff N, terminated ED Technician, followed behind. Staff R, ED Ward Clerk, watched as the patient rounded the corner at the nurses' station. At 1:34:27 PM, Patient #17, was in the wheelchair and her left arm hung limp over the armrest with her chin still on her chest.

Review of the hospital's video labeled 03/13/24 ER Waiting, showed at 1:34:39 PM, Patient #17 was slumped over in a wheelchair. The wheelchair was pushed by Staff O, ED Technician, and Staff N, terminated ED Technician, walked along side. At 1:34:46 PM, they exited the building.

During a telephone interview on 04/02/24 at 3:03 PM, Staff M, ED Physician, stated that he assessed Patient #17 at the start of his shift. At that time she was supine (lying on the back with the face and torso facing upward), arousable, and complained of generalized discomfort; but had received IV fluids and was feeling better. He did not assess Patient #17 prior to discharge. He was unaware of a change in condition and expected to be notified. Anytime a patient had a change in condition, a reassessment should be performed.

During an interview on 04/02/24 at 8:48 AM, Staff F, Chief Nursing Officer, stated that Patient #17 should not have been discharged. Patient #17 was in the ED without vital signs documented for one hour and 15 minutes, waiting on transportation.

During an interview on 04/02/24 at 8:48 AM, Staff I, Critical Care Services Director, stated that Patient #17 was waiting for transportation and was not assessed. Her expectation was that as long as the patient was at the hospital, they were responsible for the patient and she should have been assessed prior to discharge.

During an interview on 04/02/24 at 8:48 AM, Staff G, Chief Medical Officer, stated that Patient #17 had a change in condition while the hospital was waiting on lab results. Her mental status changed and she should have been reassessed prior to discharge.

During a telephone interview on 04/03/24 at 10:51 AM, Staff O, ED Technician, stated that she helped Staff Q, Licensed Practical Nurse (LPN), put Patient #17 in the wheelchair. At that time, Patient #17 was able to stand and pivot to the wheelchair with assistance. She also stated that she had given ice chips to Patient #17, who was able to use a spoon herself to eat the ice chips. She and Staff N, terminated ED Technician, took Patient #17 to the taxi at discharge. She stated that Patient #17 was "more sleepy" than she was before, but she had not reported that to anyone.

During a telephone interview on 04/03/24 at 11:11 AM, Staff R, ED Ward Clerk, stated that she was at the nurses' station when Patient #17 was discharged. She saw Patient #17 and noted she appeared to not be "with it" and did not look appropriate for a wheelchair. She stated that she did not say anything about Patient #17 to anyone.

Patient #17 was discharged to Facility B at 1:31 PM by taxi and returned by ambulance from Facility B at 2:27 PM, intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own). Patient #17 experienced a code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) and expired at 2:59 PM.

Based on interview, video review and record review, the hospital failed to provide a safe transfer for one patient (#17) of 30 Emergency Department (ED) records reviewed from 10/01/23 through 04/01/24, when Patient #17 was transported to a long-term care facility by taxi. This failure placed all patients requiring transfer at risk for their safety.

Findings included:

Although requested, the hospital failed to provide a policy that addressed criteria for discharge by a taxi.

Review of Patient #17's medical record, dated 03/13/24, showed:
- She was a 74-year-old female who arrived by ambulance from Facility B (long-term care facility) at 4:46 AM with nausea, vomiting, and diarrhea.
- Intake assessment documented level of consciousness was awake, alert, and appropriate. She was oriented to person, place, time, and situation.
- Lab work showed an elevated white blood cell (WBC, the number of white cells [infection-fighting cells] in the blood) count at 16.12 (normal is 4.5 to 11) and a low hemoglobin (Hgb, a protein in red blood cells that carries oxygen through the body) of 11.7 grams/deciliter (dl, a measurement of liquid) (normal is 12.0 to 16.0).
- A computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) of the abdomen showed liquid content in the colon and rectum indicating diarrhea and nodularity in the lower lobes of the lungs consistent with an atypical infection or aspiration (inhalation of foreign material into the lungs).
- She was given one liter of normal saline (saltwater solution), ondansetron (medication used to treat nausea) four milligrams (mg, unit of dosage strength) and metoclopramide (medication used to treat nausea and vomiting) 10 mg, intravenously (IV, in the vein).
- At 7:30 AM, she reported no nausea or diarrhea and had the ability to tolerate oral fluids.
- Her pulse rate ranged from 41 to 125, with the last recorded value of 124, at 12:15 PM.
- No vital signs were documented after 12:15 PM.
- The patient was discharged at 1:31 PM by taxi.

Review of the hospital's video labeled 03/13/24 Emergency Room (ER) Ramp East, showed:
- At 1:34 PM, a black sedan appeared to be parked under the emergency sign in the front driveway;
- At 1:35:20 PM, Staff N, terminated ED Technician; Staff O, ED Technician; and Patient #17 arrived at the black sedan and Staff N opened the front passenger side door;
- At 1:37:15 PM, Staff O walked back into the ED. Staff N stood between Patient #17 and the black sedan;
- At 1:38:17 PM, Staff O returned from the ED;
- At 1:39:18 PM, the taxi driver exited the vehicle and walked to the passenger side door;
- At 1:39:53 PM, the taxi driver appeared to lift Patient #17 into the car from her front. Patient #17's arms appeared to dangle at her sides;
- At 1:40:19 PM, Staff N walked to the driver's side and appeared to help pull Patient #17 into the black sedan;
- At 1:41:12 PM, Staff N and Staff O appeared to tilt Patient #17's head back up as it had slumped forward while applying the seatbelt;
- At 1:43:17 PM, Staff O and the taxi driver walked into the ED;
- At 1:44:28 PM, the driver returned to the car, Staff N returned to the ED; and
- At 1:44:55 PM, the black sedan drove away from the facility.

During a telephone interview on 04/03/24 at 11:11 AM, Staff R, ED Ward Clerk, stated that she was at the nurses' station when Patient #17 was discharged. She saw Patient #17 and noted she appeared to not be "with it" and did not look appropriate for a wheelchair. She stated that she did not say anything about Patient #17 to anyone.

During an interview on 04/02/24 at 2:27 PM, Staff K, ED Charge Nurse, stated that Patient #17 was awake, alert, and talking. She later observed Patient #17 standing to get into a wheelchair. She stated that patients discharged via taxi must be able to sit up on their own and have their own oxygen.

During an interview on 04/03/24 at 10:25 AM, Staff Q, ED Licensed Practical Nurse (LPN), stated that throughout the day Patient #17 was able to use her call light, voiced needs appropriately, and moved in bed for care. She stated that she assisted Patient #17 to a wheelchair prior to discharge, with Staff O, ED Technician. At the time, Patient #17 was able to stand and pivot. She stated that she took a 30-minute lunch break from 1:15 PM to 1:45 PM and gave report to Staff P, terminated ED Registered Nurse (RN). She advised Staff P the patient had oxygen on, was assisted to a wheelchair and eating ice chips, and that the taxi would arrive for discharge. She stated that her and Staff P did not visualize Patient #17 during report. She stated that she would expect Staff O, ED Technician, to know Patient #17 slumping over in the wheelchair had not been normal and to notify her.

During an interview on 04/03/24 at 10:50 AM, Staff O, ED Technician, stated that she had assisted Patient #17 with ice chips and to the wheelchair earlier in the day. She assisted Patient #17 to the taxi for discharge. She stated that Patient #17 appeared "sleepy" throughout the day. At the time of discharge, she stated that she wheeled Patient #17 out, but that Staff N, terminated ED Technician, had physically put Patient #17 into the taxi with the driver. She did not talk to Patient #17 while discharging her, so she was not aware of Patient #17's ability to answer questions. She stated that Patient #17 was "more sleepy" but assumed Staff Q, ED LPN, gave her medication. She stated that Patient #17 was able to stand and hold her head up when getting into the taxi on her own but could not pivot.

During an interview on 04/02/24 at 8:48 AM, Staff F, Chief Nursing Officer, stated that Patient #17 should not have been discharged.

During a telephone interview on 04/02/24 at 3:03 PM, Staff M, ED Physician, stated that he had assessed Patient #17 at the start of his shift. He did not assess Patient #17 prior to discharge. He was unaware of a change in condition, and he expected the nurses to notify him. He stated that Patient #17 should not have been discharged.