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Based on hospital EMTALA policy review, medical record reviews, physician and staff interviews, the hospital failed to comply with 42 CFR §489.24 Special Responsibilities of Medicare Hospitals in Emergency Cases and the related requirements at §489.20 (l), (m), (q), and (r), which pertain to the Federal Emergency Medical Treatment and Labor Act (EMTALA).

Findings included:

1. Based on hospital EMTALA policy reviews, medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physicians failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services of laboratory studies that are routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 25 sampled DED patients (#12) who presented to the hospital for evaluation and treatment for complaint of shortness of breath.
~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A-2406.

2. The hospital's Dedicated Emergency Department (DED) physicians failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 5 of 25 sampled patients (#3, #4, #13, #12 and #11) who presented to the hospital's DED with an Emergency Medical Condition (EMC) and were discharged or transferred to other acute care hospitals.
~ Cross refer to §489.24(d)(1-3) Stabilizing Treatment - Tag A-2407.

Based on hospital EMTALA policy reviews, medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physicians failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services of laboratory studies that are routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 (#12) of 25 sampled DED patients who presented to the hospital for evaluation and treatment.

Findings included:


Review on 05/17/2016 of current hospital policy "EMTALA", NH-PC-CC-1132, revised July 2013, revealed "...II. POLICY It is (Hospital A's) policy to provide care to individuals who come to the dedicated emergency department or present elsewhere with an emergency medical condition in a manner that best meets the needs of those individuals and that complies with applicable state of federal laws. ...A. Medical screening examinations 1. Individuals (including minors) entitled to a medical screening examination ...a) Individual's in the dedicated emergency department (ED) seeking medical care - When an individual comes to the dedicated emergency department of the hospital, and a request is made on the individual's behalf for a medical examination or treatment, the hospital shall provide for an appropriate medical screening examination within the capability of the hospital's emergency department, to determine whether an emergency medical condition exists. ...2. Scope of the medical screening examination a) A medical screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. The hospital shall apply in a non-discriminatory manner (i.e. a different level of care must not exist based on payment status, race, national origin, etc.) a screening process that is reasonably calculated to determine whether an emergency medical condition exists. The medical screening examination shall include both a generalized assessment and a focused assessment based on the individual's chief complaint, with the intent to determine the presence or absence of an emergency medical condition. Depending on the individual's presenting symptoms, the medical screening examination may range from a simple process involving only a brief questioning and examination for individuals who come to the facility for non-emergency services to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures. b) All individuals coming to the emergency department shall be provided a medical screening examination beyond 'login' and initial triage. ...VII. DEFINITIONS ...Capabilities - of a medical facility means that there is physical space, equipment, supplies and services....including ancillary services, that the facility provides. The capabilities of the facility's staff means the level of care that the hospital's personnel can provide within the training and scope of their professional licenses. ...Capacity - the ability of the hospital to accommodate the individual requesting examination or treatment... Capacity encompasses number and availability of qualified staff, beds, equipment... Comes to the emergency department - means with respect to an individual who is not a patient, the individual - 1. Has presented at a hospital's dedicated emergency department....and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. ...Emergency medical condition - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention reasonably could be expected to result in: 1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; 2. Serious impairment to bodily functions, or 3. Serious dysfunction of any bodily organ or part..."

2. Hospital A, closed DED record review on 05/18/2016 for Patient #12 revealed an 76 year-old female presented via private transportation to the DED on 08/31/2015 at 1435 with an arrival complaint of "shob (shortness of breath) sent by Dr. (name)." Review revealed at 1443 the patient was triaged (process of deciding which patients should be treated first based on how sick or seriously injured) by a Registered Nurse (RN). Review revealed a chief complaint of "+ (positive) Shortness of Breath (x 3 days)." Review revealed a past medical history of Anxiety, COPD (chronic obstructive pulmonary disease), Coronary Artery Disease, Diabetes Type II, GERD (gastroesophageal reflux disease), Stroke, Hypertension, et al. Review revealed at 1446 a focused assessment was performed by the RN - Airway WDL (within defined limits), Breathing WDL, and Disability WDL. Review revealed at 1447 initial vital signs were assessed as Blood Pressure (BP) 157/77, Heart Rate (HR) 83, Respirations (R) 20, Oxygen Saturation (SPO2) 96% on room air (RA), and pain was assessed as 7/10 (0 pain free, 10 worst pain). Review revealed at 1449 triage was completed and the patient was assigned a triage acuity of 3 (1 most severe, 5 least severe) and was placed into "Waiting room." Review revealed at 1511 orders were entered by triage RN for an ECG. Review revealed at 1516 an ECG was obtained. Review of the ECG revealed a machine interpretation of "Normal Sinus rhythm" and "Normal ECG." Review revealed the ECG was reviewed by Physician A (not timed) and the physician's interpretation was stamped on the ECG as "STEMI YES/NO (with NO circled)." Review revealed at 1531 the patient was placed into treatment room #9.

Review revealed at 1540 a treatment RN assessment: Respiratory - Respiratory WDL; Respiratory Pattern: Regular; Chest Assessment: Chest expansion symmetrical; Cough Present?: No; Skin Assessment - Skin Color: Appropriate for ethnicity; Skin integrity: intact; patient reports falling x3 in the last few weeks. Review revealed at 1600 "Medical Screening Exam Initiated" by Physician A. Review revealed at 1609 "Note time of service" by Physician A. Review revealed at 1616 a CXR and Ultram (pain medication) 50 mg tablet was ordered by Physician A. Review revealed at 1626 a CXR was obtained. Review of CXR radiology report dated 08/31/2015 at 1646 revealed "IMPRESSION: Mild pulmonary vascular congestion (accumulation of an abnormal amount of blood in the vascular bed of the lungs)." Review revealed at 1630 pain was reassessed as 7/10 and Ultram 50 mg orally was administered by a RN. Review revealed at 1755 the patient was moved from treatment room #9 to "Sub Waiting." Review revealed at 1825 the patient was discharged with verbal and written discharge instructions for "Shoulder Pain, Uncertain Cause" and to "Follow up with your health care provider if you don't start to get better in the next 5 days." The patient was given a prescription for Flexeril (muscle relaxer). Review revealed "Departure Condition: Improved; Stable; Discharge Instructions Reviewed with: Patient ....Mobility at Departure: Wheelchair; Departure Mode: With caregiver."

Review of MSE documentation by Physician A dated 08/31/2015 at 1741 revealed "Final diagnoses: Bilateral shoulder pain." Review revealed "CHIEF COMPLAINT: Bilateral shoulder pain HPI (History of Present illness): The patient initially mentioned that she was feeling short of breath but when she came to the room she complains of bilateral shoulder pain. The pain is in the shoulder blades. This makes it difficult for her to take deep breaths at times. She describes the pain as being a 4 - 5 out of 10 and it is almost persistent. Patient denies fever or chills. She does not have nausea vomiting or diarrhea. She denies any neurological symptoms. There is no history of travel or trauma. ROS: See HPI Constitutional: No fever Eyes: no drainage ENT: no runny nose Cardiovascular: no chest pain Resp: no SOB GI: no vomiting GU: no dysuria Integumentary: no rash Allergy: no hives Musculoskeletal: Positive for bilateral shoulder pain Neurological: no slurred speech ROS otherwise negative ...EXAM ...CONSTITUTIONAL: Alert and oriented and responds appropriately to questions. Well-appearing; well-nourished HEAD: Normocephalic EYES: Conjunctivae clear ENT (Ear Nose Throat): normal nose; no rhinorrhea; moist mucous membranes; pharynx without lesions noted NECK: Supple CARD: RRR; no murmurs, no clicks, no rubs, no gallops RESP: Normal chest excursion without splinting or tachypnea; breath sounds clear and equal bilaterally; no wheezes, no rhonchi, no rales ABD/GI: Normal bowel sounds; non-distended; soft non-tender, no rebound, no guarding BACK: The back appears normal and is non-tender to palpation, there is no CVA tenderness EXT: Normal ROM (Range of Motion) in all joints; non-tender to palpation; no edema SKIN: Normal color for age and race; warm NEURO: Moves all extremities PSYCH: The patient's mood and manner are appropriate. Grooming and personal hygiene are appropriate. ED DISPOSITION: Patient is discharged with a muscle relaxant. She's been advised to continue with her medications and to follow-up with her primary care doctor if the symptoms persisted."

Interview on 05/20/2016 at 1010 with Physician A revealed he was the physician who performed the MSE on Patient #12 when she presented to Hospital A's DED on 08/31/2015. Interview revealed upon evaluation the patient complained of pain in her shoulders. Interview revealed the patient denied shortness of breath or any respiratory complaints. Interview revealed the patient was having bilateral shoulder pain and "not cardiac pain." Interview revealed the patient was alert and oriented, to person, place, and time, afebrile, her bilateral breath sounds were clear, and chest was normal. Interview revealed her ECG was normal. Interview revealed based on the patient's clinical presentation he ordered an ECG and chest x-ray. Interview revealed he did not order any labs. Interview revealed the patient was given discharge instructions and a prescription for a muscle relaxer. Interview revealed the patient had an EMC. Interview revealed the patient was "stable" upon discharge.

In summation, Patient #12 presented via private transportation to Hospital A's DED on 08/31/2015 at 1435 with complaints of shortness of breath. The MSE was performed by Physician A. An EKG, CXR, and Ultram (pain medication) were ordered. No laboratory studies were ordered. Review revealed at 1825 the patient was discharged with verbal and written discharge instructions for "Shoulder Pain, Uncertain Cause" and to "Follow up with your health care provider if you don't start to get better in the next 5 days." The patient was given a prescription for Flexeril (muscle relaxer). Review revealed a diagnosis of bilateral shoulder pain. The patient was discharged with a muscle relaxant and advised to continue with her medications and to follow-up with her primary care doctor if the symptoms persisted." The hospital's DED physician failed to provide an appropriate MSE within the capability of the hospital's DED, including ancillary services, laboratory services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for Patient #12, on 8/31/2015 given the patient's Chest x-ray showed mild pulmonary congestion.




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Based on hospital EMTALA policy review, medical record reviews, staff and physician interviews the hospital's Dedicated Emergency Department (DED) physicians failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 5 of 25 sampled patients (#3, #4, #13, #12 and #11) who presented to the hospital's DED with an Emergency Medical Condition (EMC) and were discharged or transferred to other acute care hospitals.

Findings included:




POLICY It is (Hospital A's) policy to provide care to individuals who come to the dedicated emergency department or present elsewhere with an emergency medical condition in a manner that best meets the needs of those individuals and that complies with applicable state of federal laws. ...C. Stabilization of individuals in the dedicated emergency department who have an emergency medical condition 1. General standards - Individuals in the dedicated emergency room. Review on 05/17/2016 of current hospital policy "EMTALA", NH-PC-CC-1132, revised July 2013, revealed "...II. department who have an emergency medical condition shall receive necessary stabilizing treatment or an appropriate transfer to another medical facility. 2. Stable for transfer - An individual in the dedicated emergency department whose emergency medical condition has not been resolved may be stable for transfer from one facility to another facility if the treating physician has determined, within reasonable clinical confidence, that the individual is expected to leave the hospital and be received at the second facility with no material deterioration in his or her medical condition and the treating physician reasonably believes that the receiving facility has the capability to manage the individual's medical condition and any reasonable foreseeable complication of that condition. ...4. Stable for discharge - An individual is considered stable for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, reasonably could be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. ...VII. DEFINITIONS ...Capabilities - of a medical facility means that there is physical space, equipment, supplies and services....including ancillary services, that the facility provides. The capabilities of the facility's staff means the level of care that the hospital's personnel can provide within the training and scope of their professional licenses. ...Capacity - the ability of the hospital to accommodate the individual requesting examination or treatment... Capacity encompasses number and availability of qualified staff, beds, equipment... Comes to the emergency department - means with respect to an individual who is not a patient, the individual - 1. Has presented at a hospital's dedicated emergency department....and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. ...Emergency medical condition - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention reasonably could be expected to result in: 1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; 2. Serious impairment to bodily functions, or 3. Serous dysfunction of any bodily organ or part; ...Stabilized - with respect to an emergency medical condition means that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility....A patient will be deemed stabilized if the treating physician of the individual with an emergency medical condition has determined, within reasonable clinical confidence, that the emergency medical condition has been resolved. To stabilize - means with respect to an emergency medical condition to provide such medical treatment of the condition necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility..."



1. Hospital A, closed DED record review on 05/18/2016 for Patient #3, revealed a 85 year-old male presented via EMS (emergency medical services) ambulance from an Assisted Living Center to the hospital's DED on 01/24/2016 at 0806. Review of Patient Care Timeline revealed a chief complaint at 0809 of "difficulty breathing and nausea for 3 days. Patient sitting up talking to EMS and had no complaints upon arrival." Patient received 600 cc (cubic centimeters) of normal saline, pulse ox (pulse oximetry non- invasive method measures oxygen content in the blood -Normal oxygen levels 96% to 100%) 84% on 15L (liters) non-rebreather enroute. Arterial blood gases (ABGs-the sampling of blood levels of oxygen and carbon dioxide within the arteries) were ordered at 0810 by respiratory therapy and results revealed: ABGs - pCO2 (carbon dioxide) - 25, pO2 (oxygen) - 308, HCO3 (bicarbonate - 11, O2 Sats - 100%. Review revealed Patient #3's vital signs at 0821 via monitor were: HR (heart rate) 101 and T (temperature) - 98° F (Fahrenheit) [rectal]. The patient was seen by Physician A at 0814, orders placed included: XR (x-ray) Portable chest AP (anterior/posterior), ECG (electrocardiogram) 12 Lead, CBC (complete blood count) and Differential, TROPONIN T, Pro time-INR, PTT, PROBNP, COMPREHENSIVE METABOLIC PANEL, Blood Gas, Arterial; O2 @ 2L via nasal cannula, Titrate to keep SATS: >92%, insert peripheral IV (intravenous). At 0903, IVF (intravenous fluids) of Na Cl (sodium chloride) rate increased to 250 cc/hr (cubic centimeters/hour). Blood cultures were drawn. Patient roomed at 0818. Triage completed at 0820.


Review revealed vital signs were reassessed at:
0849 - BP (blood pressure) 101/54;
0858 - BP 96/46, HR 90, R (respirations) 26, T rectal 98° F, and SpO2 99% (2L via Nasal Cannula);
0908 - BP 91/60, HR 96, R 29, and SpO2 98%;
0919 - BP 69/14, HR 98, R 30, and SpO2 98%;
0928 - BP 74/44, HR 88, R 19, and SpO2 99%;
0940 - BP 118/67, HR 87, R 34, and SpO2 94%;
0958 - BP 89/32, HR 78, R 24, and SpO2 85%;
1008 - BP 101/70, HR 90, R 24, and SpO2 97%;
1015 - BP 81/47, HR 79, R 12, and SpO2 98%;
1042 - BP 114/49, HR 94, R 28, and SpO2 98%;
1052 - BP 111/30, HR 88, R 26, and SpO2 98%;
1112 - BP 104/60, HR 86, R 12, and SpO2 94%;
1153 - BP 129/77, HR 65, R 21, and SpO2 93%;
1222 - BP 91/48, HR 81, R 27, and SpO2 95%;
1300 - BP 82/34, HR 75, R 35, and SpO2 no value;
1332 - BP 100/43, HR 76, R 14, SpO2 79%; and
1431 - BP 106/81, HR 68, R 34, SpO2 87%.



Review of MSE (medical screening exam) documentation by Physician A dated 01/24/2016 at 0833 revealed, "Chief Complaint Difficulty Breathing ...HPI (history of present illness) patient did not appear to be in respiratory distress and denies chest pain....says he has generalized abdominal discomfort." Past medical history included: hypertension, stroke (right sided weakness), a-fib (atrial fibrillation), diabetes, arrhythmia, CHF (congested heart failure), CAD (coronary artery disease). Past surgical history included: BKA (below knee amputation), AKA (above the knee amputation), hip replacement and cardiac pacemaker. Patient was followed by the Veteran's Administration Hospital. Review of Systems A comprehensive review of systems was negative except Respiratory: Patient has a decreased inspiratory effort. There is no evidence of rhonchi or rales or wheezing. Patient is fairly vague about his respiratory complaints. The family insisted he was short of breath but the patient denies being short of breath. Review of Chest X-ray result - cardiomegaly, pacemaker. Moderate right pleural effusion with right basilar atelectasis/infiltrate. Review of CT (computed tomography) - abdomen pelvis w/o (without) contrast resulted at 1042 revealed "1. Moderate right pleural effusion with right middle and right lower lobe atelectasis/infiltrate. 2. Cardiomegaly 3. Fatty liver 4. Gallbladder wall calcification suggesting developing porcelain gallbladder ...left upper quadrant and pelvic ascites..." Review of lab results revealed Pro BNP - 35,000 pg/ml [Reference Range: <=899], Troponin T - 0.138 [Reference Range: <=0.009], Potassium - 5.8 2 [Reference Range 3.7 - 5.4]. , PT - 97.4 [Reference Range: 10.0 - 11.8], PTT - 46 [Reference Range: 21-36], INR - 9.54 [Reference Range: 2.0 - 3.0], Creatinine - 3.62 [Reference Range 0.76 - 1.27], BUN 75 ...Clinical Impression Final Diagnoses: "Generalized abdominal pain, renal failure, other ascites, pleural effusion and anticoagulant over dosage, accidental or unintentional." Review revealed at 1104 a Hospitalist consult was ordered. At 1106 Physician A ordered IVF rate decreased to 100 ml/hour (milliliters/hour). At 1139, after Physician K's (Hospitalist) consult was completed, decision was made to transfer patient.



Review of Physician K's consult dated 01/24/2016 at 1148 revealed "Recommendations: Sepsis secondary to pneumonia and possible cholecystitis, Acute kidney injury with unknown chronic kidney disease stage, Acute or chronic systolic CHF with unknown ejection fraction, Hypotension due to sepsis, Acute hypoxic respiratory failure, Pleural effusion, Acute encephalopathy unknown etiology, Abnormal liver function tests in the setting of porcelain gallbladder, Abnormal troponin with abnormal EKG, Over anticoagulation, Atrial fibrillation, Peripheral vascular disease ...Code Status ...DO NOT RESUSCITATE/DO NOT INTUBATE (DNR/DNI) status. However would want appropriate aggressive measures performed to treat the above mentioned problems ...HPI ...Patient seen....is awake and talking....color poor. ...obvious right upper quadrant tenderness. ...Physical Examination: General: Elderly ill appearing male in mild respiratory distress. ...LUNGS: Crackles right side with decreased breath sounds. ...CV (cardiovascular): Irregular rhythm but on telemetry which demonstrates pacing and intermittent PVCs (pre-ventricular contractions). Positive 2/6 murmur. ABD (abdomen): Distended. Right upper quadrant tenderness with palpation. Noted mottling on abdomen. ...Neuro: Alert to his name and actually provides some medical history..."

Review of medication orders by Physician A revealed at 1139 ZOSYN (antibiotic) 3.375 g (grams) in Na CL 0.9% 100 mL was ordered


Review of Physician's ED Notes at 1139 revealed calls to the Veteran's Administration (VA Hospitals) at two separate locations were made seeking an available bed for Patient #3. There were no beds available. A transfer to (Hospital C) was agreed upon. Review revealed at 1207, "Reviewed the results and discussion with the patient and family. ...they are in agreement with this plan. Discussed with (Physician N), receiving physician at (Hospital C). Transfer arrangements were then made to neighboring acute care facility." Review revealed transfer order and certification detailing risks and benefits was accomplished at 1426.


Review of ED Provider Note on 01/24/2016 at 1611 (Late entry) revealed "At 1500 hrs. EMS here to transfer the patient. Pt. is stable and comfortable at the time of discharge. Pressure is 106/81. The patient is on oxygen. Discussed the transfer process with the patient and the family. Patient left the emergency room."


Review of Patient Transfer Order and Certificate dated 01/24/2016 at 1426 revealed Physician A had placed the transfer order, communicated with receiving Physician N at Hospital C, described risks and benefits as "higher level of care" and secured Patient #3's consent and signature. A copy of medical records were sent via Hospital C's critical transport team.


Review of Hospital C's Critical Care Transport documentation revealed arrival at 1510 to Hospital A. Patient #3 was assessed at 1510 and was transferred via critical care transport at 1525. Continued review revealed "1525 Departed....Awake, alert, oriented; NS (normal saline) infusing @ 100 ml/hour; Not complaining of abdominal pain; no nausea; Monitor shows paced rhythm; Respirations shallow and rapid but maintaining O2 sat 93 - 94% on 2L NC; 1545 Resting comfortably. ...B/P unchanged. ...1555 Pt. became unresponsive; skin color changed from pale to blue; B/P 63/49 but we cannot feel pulse; CPR started; called ED charge; Pt stiff especially neck & head....After bagging for 30 seconds attempted intubation which was unsuccessful; CPR & bagging continued; 1557 Arrived @ (Hospital C)."


Hospital C closed medical record review for Patient #3 revealed patient arrived via ambulance and was admitted to the ED on 01/24/2016 at 1607. Review of provider note dated 01/24/2016 at 1646 revealed HPI Comments: "Pt. transported here via EMS for....admission for sepsis. His labs showed elevated troponin, shock liver, renal failure, sepsis, elevated INR. His son said his lips were cyanotic the whole time while he was there (Hospital A). During transport to named facility (Hospital C) he went into asystole. Was given epi/atropine and compressions without return of pulses. Unsuccessful intubation. ...4:46 PM Discussed critical status of patient with family including wife and children. They said he was DNR/DNI and would not have wanted intubation or CPR. He was pronounced dead at 1646..."


Interview on 05/19/2016 at 1540 with Physician A revealed he was the physician who performed the MSE on Patient #3 on 01/24/2016 at Hospital A. He reviewed the patient's electronic medical record during the interview. Interview revealed the patient had chronic breathing issues and was able to speak to him and showed no respiratory distress initially. Interview revealed as the patient's blood pressures started to change he asked for a Hospitalist consult and ordered intravenous fluids to infuse at 250 ml/hour, which stabilized the BPs enough so "I did not think vasopressors were necessary." Interview revealed the decision was made to transfer the patient because "we do not have the capability of caring for such a sick man here." Interview revealed Physician A would not have proceeded with the transfer had he been made aware of the dropping BPs by the critical transport team. Patient #3's condition was not stable at the time of transfer as evidenced by failing to stabilize the patients hypotension (low blood pressure, and dropping ) and failing to protect the patient's airway due to acute respiratory failure he was in prior to transferring the patient to another acute care hospital.


In summation, Patient #3 presented via ambulance to Hospital A's DED on 01/24/2016 at 0806 for difficulty breathing and nausea for 3 days. The MSE was performed by Physician A. Diagnostic laboratory and radiological studies were obtained. Review revealed a clinical impression of "Generalized abdominal pain, renal failure, other ascites, pleural effusion and anticoagulant over dosage, accidental or unintentional." The Hospitalist consult revealed sepsis secondary to pneumonia and possible cholecystitis, acute kidney injury with unknown chronic kidney disease stage, acute or chronic systolic congestive heart failure with unknown ejection fraction, hypotension due to sepsis, acute hypoxic respiratory failure, pleural effusion, acute encephalopathy unknown etiology, abnormal liver function tests in the setting of porcelain gallbladder, abnormal troponin with abnormal EKG, over anticoagulation, atrial fibrillation, and peripheral vascular disease. The patient was transferred to Hospital C via Critical Care Transport ambulance. Enroute the patient became hemodynamically unstable and unresponsive. CPR was started. The patient arrived at Hospital C's DED on 01/24/2016 at 1607 and was pronounced dead at 1646. The hospital failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize Patient #3's emergency medical condition 01/24/2016.



2. Hospital A, closed DED record review on 05/18/2016 for Patient #4 revealed a 61 year-old male presented ambulatory via private transportation to the hospital's DED on 01/04/2016 at 1517. Review of "Arrival Complaint documentation revealed the patient presented with reported "shob (Shortness of Breath)." Review of Triage documentation revealed the patient was triaged by RN #16 at 1527. Review revealed vital signs were assessed as Temperature (T) 97.2 degrees Fahrenheit (F), Heart Rate (HR) 98, Respirations (R) 18, Blood Pressure (BP) 132/85, Oxygen Saturation (SpO2) 99% on room air. Review revealed "Chief Complaints Updated: Shortness of Breath (reports onset of cough and shortness of breath since before Christmas). Reports he had a CT (computed tomography) of his chest today in out patient [sic]) at 1528." Review of Pivot Triage Assessment documentation by RN #16 revealed, the patient reported his pain level as "No/denies pain." Review revealed the patient was triaged as a priority 3 (Emergency Severity Index 1-5, 1 most severe, 5 least severe). Review revealed the patient was placed into treatment room #7 at 1547 and assigned to RN #2. Continued review of nursing assessment documentation revealed a Glasgow Coma Scale (GCS) [used to gauge level of consciousness] Score of 15 (Severe: GCS 3-8, Moderate: GCS 9-12, Mild: GCS 13-15). Review revealed, "Level of consciousness - Oriented. Respiratory - Patient reports Shortness of breath (x1 month)." Review revealed "Bilateral Breath Sounds: Clear and equal" with "Regular breathing pattern." Review of discharge documentation revealed the patient's condition at discharge "Improved, Stable" at 1850. Discharge instructions reviewed with the patient with education material for "Embolism" provided. Review revealed at 1850, vital signs were reassessed as HR 97, R 16, BP 137/102, and SpO2 99% on room air. Review revealed a pain score: 3 (0 pain free, 5 worst pain). Review revealed final diagnoses included, "Other pulmonary embolism without acute corpulmonale (heart disease), Essential hypertension, Long term (current) use of aspirin, Other long term (current drug therapy)."



Review of MSE documentation by Physician A at 1555 revealed the patient's chief complaint was "Shortness of Breath (SOB)." Review revealed the patient reported the "onset of cough and shortness of breath since before Christmas. reports [sic] he had a CT of his chest today in out patient [sic]." Review revealed, "He denies any fever or chills. he [sic] just would like to find out what's the cause of his shortness of breath." Review revealed the patient "had a CT scan as an outpatient today and he decided to come to the emergency room to get checked out to further evaluate this. The patient denies any other symptoms per say. History of pneumonia involving the right lung and this was in June 2015. Please note the patient is saturating at 99% on room air." Review revealed a "Past Medical History of HTN (hypertension), Lung involvement in other diseases classified elsewhere Lung failure, Pneumothorax, Lung edema." Review revealed the patient was followed by Physician J (Pulmonologist) on an outpatient basis. REVIEW OF SYSTEMS (ROS) revealed "Constitutional: Negative for fever. Cardiovascular: Negative for chest pain. Respiratory: Negative for shortness of breath....Neurological: Negative for headaches, weakness or numbness....PHYSICAL EXAM: VITAL SIGNS: ED Triage Vitals....Blood Pressure (BP) 01/04/2016 1528 132/85 Heart Rate (HR) 98; Respirations (R) 18; Temperature (T) 97.2 degrees Fahrenheit, SpO2 99%. Constitutional: Alert and oriented ...HEENT (Head, Ears, Eyes, Nose, Throat) Cardiovascular: Regular rate and rhythm. No murmur, Good distal peripheral pulses. Pulmonary/Chest: Normal respiratory Effort ...Neurological: Normal speech and language. No gross focal neurological deficits....Psychiatric: Normal mood and affect. Speech and behavior are normal." Review revealed "Clinical Impression: None [sic]." Review revealed, "ED COURSE: Pertinent labs & imaging results that were available during my care of the patient were reviewed by me....6:30 PM Patient follows with (Physician J) the pulmonologist. I have started the patient on anticoagulation for his pulmonary embolus. He is to follow-up with (Physician J) in 2 days. Given for [sic] Coumadin (anticoagulant) and His First Dose of Lovenox (anticoagulant) Was Given in the Emergency Room."



Review of "Medications - Clinical Orders" by Physician A at 1727 revealed orders for "Lovenox injection 60 mg (milligrams) subcutaneously," administered by RN #2 at 1737 and "Coumadin 5 mg by mouth," administered by RN #2 at 1849. Review revealed a prescription order from Physician A at 1825 for Coumadin 5 mg tablet (3 tablets), "Take 1 tablet (5 mg total) by mouth daily."


Review of "Lab - Clinical Orders" by Physician A revealed the following labs ordered and resulted:
1. Basic Metabolic Panel "STAT" : Creatinine 1.44 [Reference Range 0.76 - 1.27];
2. ProBNP "STAT": 5982 [Reference Range: <=899];
3. PT 13.3 [Reference Range: 10.0 - 11.8];
4. INR: 1.23 [Reference Range: 2.0 - 3.0]; and
5. PTT 29 [Reference Range: 21-36].


Review of radiology report from CT scan performed in outpatient prior to DED presentation revealed, "RADIOLOGY: CT Chest W (with) Contrast: 01/04/2016 INDICATION: ...Pleural effusion (an accumulation of fluids in the lung or in the chest), not otherwise classified ...images were obtained through the chest ...COMPARISON: CTPA date 6/1/2015 FINDINGS: ...Lungs: Moderate somewhat loculated (cavity of fluid) pleural effusions are present bilaterally (both) with or [sic] calcifications along the posterior right upper lobe and at the left lung apex. ...Glass infiltrates of both lungs with linear areas of atelectasis, scar or rounded atelectasis of the right mid to lower lung and atelectasis or infiltrate of the right lower lobe. ...Vasculature: Incidental filling defect of the posterior basal segmental pulmonary artery on the right. 01/04/2016 IMPRESSION: 1. Filling defect of a right lower lobe pulmonary artery representing pulmonary embolus. 2. Moderate loculated effusions bilaterally with pleural calcifications similar to the previous exam. This is nonspecific and can be seen with fibrotic or ileus no lung disease, sarcoidosis, collagen vascular disease or early in pleural-based neoplasm. No nodularity or mass is identified to suggest neoplasm. 3. Mild groundglass opacities of both lungs with areas of nodularity resolved form the previous study. 4. Atelectasis or infiltrate and possible early round atelectasis of the right lower lobe. CODE CRITICAL
REPORT."

Record review revealed the patient was discharged from the DED on 01/04/2016 at 1853 with instructions to follow-up with Physician J in 2 days and a prescription for Coumadin.

Record review revealed no available documentation of a consultation with the pulmonologist (Physician J).

Review of Hospital A's DED Specialty On-Call physician's roster revealed pulmonology was available on-call on 01/04/2016 during Patient #4's DED visit.

Review on 05/19/2016 of a "Patient Encounters" form for Hospital A, revealed Patient #4 was directly admitted to Hospital A on 01/07/2016 (3 days following presentation to the DED on 01/04/2016) and was discharged on 01/14/2016. Review revealed the reason for admission was "SOB" (Shortness of Breath).


Hospital A, closed inpatient medical record review on 05/18/2016 for Patient #4 revealed an admission date of 01/07/2016 at 1120. Review of History and Physical (H&P) documentation by Physician D at 1329 revealed, "Chief Complaints: Directly admitted by (Physician J) for treatment of PE (pulmonary embolism-blockage of blood vessel in the lungs) and further workup will [sic] pleural effusion and epigastric pain. History of Present Illness: ...history of exposure to asbestos and a recent diagnosis of PE on a background of hypertension, chronic systolic congestive heart failure. The patient has had a thoracentesis (surgical procedure to remove fluid from the space between the heart and lungs) in June which yielded bloody pleural effusion....His pulmonologist wants him to have another imaging guided thoracentesis. The patient's only complaints are cough and epigastric pain....he denies hemoptysis (blood tinged sputum)....His pulmonologist wants to [sic] him to be seen by a gastroenterologist....3 days ago he was in the ED and was diagnosed with pulmonary embolism and apparently sent home on 3 tablets of Coumadin after an injection in his belly and [sic] according to the patient. He followed up with his (Physician J) today who wanted him to be directly admitted for heparin anticoagulation. His BNP (blood test results help determine if a patient has heart failure) has increased from 3707 months ago to almost 6000 currently. Review of Systems: Pertinent positives and negatives detailed in history of present illness. Remaining 12 system review is unremarkable. Past Medical History Diagnosis: HTN (hypertension), Lung involvement in other diseases classified elsewhere Lung failure, Pneumothorax, Lung edema. Physical Exam: CV (cardiovascular) - (+) S1S2 (heart sounds), no murmurs or gallop....No JVD (jugular vein distention). Resp (respirations) - Symmetrical and adequate chest expansion. Right lower lobe decreased air entry and coarse crackles ....GI - (+) BS (bowel sounds), soft, mild to moderate epigastric tenderness with some guarding but no rebound. ...Skin - No. ...peripheral edema. Neuro - alert, aware, oriented to person/place/time ...Psych - Appropriate affect....Normal cognition and intellect....Recent Labs: 01/04/16 1725 Creatinine 1.44; BNP 5982..."



Review of the Plan of Care (POC) initiated by (Physician D) revealed the plan was developed and implemented on 01/07/2016 at 1329. Review revealed "Pulmonary embolism, Pleural effusion, bilateral, and CHF (congestive heart failure). Principal Problem: Pulmonary embolism. started [sic] on heparin drip. (Physician J) doesn't want us to transition him to oral anticoagulation until GI (gastroenterology) sees him. Pleural effusion, bilateral (both). Case discussed with (Physician J). The patient apparently had exposures to assess [sic] and had a recent thoracentesis which yielded bloody effusion but results are incomplete and he wants it to be repeated. Active Problems: CHF, NYHA (New York Heart Association) class III, acute on chronic, systolic [sic]. BNP higher than baseline. This restarted on IV diuresis. Patient has had a recent echo (echocardiogram) 3 weeks and [sic] we will try to obtain those results. Patient is on aspirin, beta blocker, Lasix, spiral lactone. Essential hypertension: controlled with beta blockers. Asbestosis: see above under poor [sic] effusion." Review of Electrocardiogram (ECG) 12-Lead Narrative on 01/09/2016 at 0959 review revealed an order by (Physician D) on 01/07/2016 at 1841. Review revealed, "Diagnosis Sinus tachycardia Possible Left atrial enlargement ...Anterior infarct, age undetermined ...Abnormal ECG When compared with ECG of 03-Jun-2015 1513, Anterior infarct is now present ..."



Review of a progress note by Physician J on 01/11/2106 at 2009 revealed, "She [sic] has been on heparin drip because of pulmonary embolism. he [sic] does have significant effusion on the right side with calcification recent thoracentesis did not prove to be helpful I think is [sic] asbestos effusion however cannot rule malignancy. He [sic] had upper GI endoscopy done. Did not show any pathology given his complicated kidney disease cardiomyopathy with congestive heart failure and significant blood tinged effusion on the right side. it [sic] may be a good idea for him to have a cardiothoracic surgery consultation as an inpatient I would therefore recommend the patient to be transferred over to (acute hospital) to have a cardiothoracic surgery consultation while on the heparin drip so that any intervention if needed could be done. I would continue other supportive care at this time. ...Physical Exam Chest scattered rales bilaterally right more than left with dull percussion in the right base..."


Review of progress note by Physician J on 01/12/2016 at 1239 revealed, "Patient is in the process of being converted to oral anticoagulation. He does have a pleural effusion that may be associated with his fiberglass exposure at (corporation), however is also a risk for malignancy. Patient does not want transfer to (acute hospital) unless necessary..." Progress note by (Physician P) on 01/12/2016 at 2230 review revealed the patient "has been undergoing thoracentesis every 6 months. Most recent was done during this admission with removal of 1000 cc. ...Recommendations CT scan of the chest was reviewed. Pleural effusion with pleural thickening....Concerns are related to the recent PE. Continue the heparin drip..." POC update by (Physician D) on 01/13/2016 at 1549 revealed, "Principal Problem: Pulmonary embolism asymptomatic in terms of chest pain and hemoptysis. No shortness of breath. The surgeons have decided that at this moment won't [sic] be any thoracic procedures done because of the high risk related to his PE. I'll start him on Coumadin and heparin. And discharge him most likely on Lovenox and Coumadin. Pleural effusion, bilateral underwent thoracentesis. Pleural fluid analysis pending....Asbestosis I spoke with (Physician Q) (acute hospital) Thoracic surgery and recommended discharged [sic] on Lovenox and follow-up at his office for possible biopsy..."



Review of "Hospital Discharge Summary" documentation by PA #2, cosigned by Physician K on 01/14/2016 at 1304 revealed, "PRINCIPLE DISCHARGE DIAGNOSIS: Acute Pulmonary embolism Principle Problem: Pulmonary embolism. Active Problems: Hypertension CHF (congestive heart failure), NYHA class III, acute on chronic, systolic Essential hypertension Pleural effusion Cardiomyopathy, dilated, Nonischemic Asbestosis CKD (chronic kidney disease), stage III. BRIEF HOSPITAL COURSE: This 61 y.o. (year old) male with history of exposure to asbestos and a recent diagnosis of PE, with comorbidities of hypertension, congestive heart failure with EF (ejection fraction) 30%, cardiomyopathy, and recent history of pneumonia [sic]. He is followed by cardiology with (Physician F) and pulmonary by (Physician J). He was a direct admission from (Physician J) office for management of pulmonary embolism and workup of loculated pleural effusion in the settling of exposures to asbestos, history of pneumonia and congestive heart failure. His pulmonary issues are not new. ...and is now followed by (Physician J). At the time of admission, patient had recently been to (Hospital A) ED for SOB and CP (chest pain) and found to have Acute PE, he was given one dose of Lovenox followed by 3 doses of Coumadin. He then presented to (Physician J) office for follow up. (Physician J) wanted the patient to have follow up image guided thoracentesis but patient was having epigastric pain and he felt it best that patient have EGD (esophagogastroduodenoscopy: scope of esophagus, stomach, and first part of the small intestine) before beginning oral anti-coagulation ....Patient is currently doing well, no active complaints. He is rather upset feeling as though nothing has been done for his pulmonary issues....He was going to be transitioned to Coumadin however, his INR today is still not therapeutic..." Vital signs: T 97.6 degrees Fahrenheit, HR 82, Resp 18, BP 120/76, SpO2 99% on room air.



Concurrent interviews on 05/19/2106 at 1620 with Physician D and Physician K (Physician D's supervisor) revealed Patient #4 was admitted on 01/07/2016 by Physician D. Interview revealed Physician J called and requested the patient to be directly admitted for further evaluation and treatment of an acute pulmonary embolus and further workup of the effusion noted on the CT scan. Interview revealed Physician J wanted a repeat thoracentesis. Interview revealed the patient's comorbidities, EF (Ejection Fraction) of 30%, the increase in the BNP (B-Natriuretic peptide) level were of concern enough for Physician D to admit the patient. Interview revea