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Based on observation, interview, and document review, the hospital failed to implement its policies and procedures for the evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA).

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death.

Findings included:

The hospital failed to reasess a patient when the patient had changes in their vital signs prior to discharge from the emergency department (ED).

Cross-reference: Tag A-2407

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Based on interview and document review, the hospital failed to reasess a patient (Patient #1) when the patient had changes in their vital signs prior to discharge from the emergency department (ED) for 1 of 25 patient records reviewed.

Failure to ensure patients receive a comprehensive medical screening exam reassessment when they have changes in their vital signs or other changes in their medical condition puts patients at risk for poor health outcomes, injury, and death.

Findings included:

1. Record review of the hospital's policy and procedure titled "Emergency Department Discharge Procedure", approval 10/18, showed that changes in a patient's vital signs from the baseline or changes in a patient's medical condition needed to be reported to the assigned medical provider for reassessment prior to discharge.

2. On 07/08/19 at 1:08 PM, the investigator interviewed a contact (Contact #1) for Patient #1. The contact made all decisions for Patient #1. The contact stated that the patient had been discharged back to their commuity care facility after being seen in the ED. The community care facility continued to be concerned about the patient's heart rate and sent the patient to another hospital for an evaluation. The patient was admitted for sepsis (severe infection) and was in the hospital for several weeks.

3. Review of Patient #1's medical record showed the patient was sent to the ED on 02/09/19 due to hematuria (blood in the urine) in their urinary catheter bag. The patient had a history of chronic lower urinary tract obstructions and a history of urinary tract infections.

a. Vital signs (VS) on admit to the ED at 9:41 AM were Temperature (T) 97.9, Pulse (P) 54, blood pressure (BP) 116/76.

b. The physician examined the patient at 10:53 AM. At the time of the physician's exam the pulse (P) was 98. The physician made note the patient's urinary catheter was draining freely. The urinary catheter had been inserted by the urologist several days earlier after the home health nurse had not been able to insert a new urinary catheter for the monthly urinary catheter replacement. The patient was scheduled to have a suprapublic catheter (catheter inserted through the abdomen into the bladder for release of urine) by their urologist in the next month. The physician ordered an Electrocardiogram (EKG). The EKG showed sinus rhythm arrthymia with T-wave abnormality

c. VS at 2:00 PM showed the P had increased to 113, BP had increased to 136/87, and T was 98.

d. At 2:14 PM the patient had been discharged back to their community care facilty. The increase in the patient's heart rate of 113 and BP 136/87 changes were not reported to the attending ED physician.

4. On 07/09/19 at 11:00 AM, the investigator interviewed a licensed nurse in the ED (Staff #9). The nurse stated that changes in a patient's vital signs before discharge needed to be reported to the attending ED physician to ensure patients were being sent home in a stable condition.

5. On 07/09/19 at 1:30 PM, the investigator interviewed a licensed nurse working in the Quality department (Staff #12). Staff #12 verified the above findings.

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