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Based on review of documentation and interview, the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) existed for 1 of 1 patient (Patient #1) reviewed that presented to the emergency department (ED) on 1/25/19 and returned 1/26/19 (18+ hours later); presenting with an EMC.

Specifically, Patient #1 did not receive an appropriate and thorough MSE to include blood related laboratory tests during her first visit on 1/25/19 that may have detected her potential EMC and diagnosis resulting in Intensive Care Inpatient treatment on 1/26/19.

Findings were:

Review of the Complaint Intake TX 00319984 indicated the following allegations on behalf of Patient #1.

Patient #1 is a 55-year-old female with the diagnoses of Intellectual Developmental Disorder (Mental Retardation), Schizophrenia, Bipolar Disorder, and Seizures. Patient was noted to be ambulatory and interviewable. The allegations made was that the facility failed to provide adequate care and a complete thorough assessment on 1/25/19.

Patient #1 was taken to the Emergency Department (ED) by Emergency Management Services (EMS) on 1/25/19 at 10:29 PM due to becoming "non-verbal, disoriented, and groggy." There was swelling in both legs. Patient #1 was discharged home after assessment and was told she "had an infection, but did not know where or anything else." Patient #1 was given diagnosis of "viral syndrome." Patient #1 was told to take Tylenol, that there was nothing more the ED could do.

Approximately 18 hours later, Patient #1 was unable to ambulate, collapsed in the bathroom, and was unresponsive. Patient #1 was taken back to the facility's ED by EMS. After assessment, Patient #1 was admitted to the Intensive Care Unit (ICU); diagnosed with a severe Urinary Tract Infection (UTI), Infection, and Pneumonia. Patient was discharged on 2/3/19 (8 days later).

Review of the EMS Record dated 1/25/19 at 21:45 revealed the following documentation:
Patient [#1] was found sitting on chair. Patient [#1] has been complaining of body pain throughout her body. When asked, patient states that her whole body hurts, patient denies any nausea or vomiting. Patient temperature assessed, noted to be at 102.6 Fahrenheit (F). Vital Signs taken at 21:53 indicated heart rate at 135 beats per minute (high), Blood Pressure 107 systolic with 86 diastolic, Respirations 18 (breaths per minute), Glucose 118. Patient loaded into ambulance without incident. Patient was placed on 12 lead ECG. IV was established, 18 gauge to left wrist. Patient administered acetaminophen 1gram by mouth. Patient transported to [facility] without incident. Patient transported to undergo emergency treatment and evaluation due to body pain, hyperthermia, "rule out Sepsis."

1.) Review of Patient #1's ED Physician-A record dated 1/25/19 at 22:29 (10:29 PM) revealed patient arrive by ambulance; presented to the ED with report of general body pain. EMS reports a fever of 102.6 F (Fahrenheit) to which they gave a gram of Tylenol. Temperature after Tylenol was 102.8 F (increased). Vital signs taken at 22:34 upon arrival revealed temperate at 102.4 F, Pulse rate 132 beats per minute (bpm); high, oxygen saturation rate of 97%, and blood pressure 133 systolic with 83 diastolic (within normal parameters). Further vital signs reassessment at 23:30 revealed Temperature at 99.0 F, Pulse Rate at 110 bpm (high), and blood pressure 107/58 diastolic (low).

Medical Decision Differential Diagnosis: Arthritis, viral syndrome, anxiety.

Physician Orders (PO) included: Vital Signs, Chest X-Ray (1 view frontal), Influenza A/B Antigens Rapid Screen, Rapid Strep Throat (Strep Group A), Culture Throat, Urinary Analysis (UA) Microscopic, Motrin 800mg and Intravenous Sodium Chloride. In addition to the Physician Orders; the medical records "SYSTEM" populated an order to "Notify Provider of Clinically Indicated Sepsis Risk." Order comment: "Order placed due to patient meeting criteria for [Systemic Inflammatory Response Syndrome] SIRS/Sepsis by @MISC:8." Further review of the PO's revealed there were no blood level labs ordered for evaluation of Sepsis.

Review of the UA lab results revealed urine mostly negative except for positive Blood (>=1.0 mg/Dl lg), and Hyal Cast (3-8).
Strep Group A and Flu A/B were negative.

Chest X-ray taken 1/25/19 at 22:45 revealed the chest is clear of acute pneumonic infiltrates, edema, pneumothorax, and gross pleural fluid.

There were not any other laboratory orders or results for blood tests (i.e. Complete Blood Count, Basic Metabolic Panel, etc.)

Physician A's final impression and plan was Viral Syndrome - Discharge Home. Patient discharged from ED on 1/26/19 at 00:26 (12:26 AM).

2.) Review of Patient #1's - 2nd ED record dated 1/26/19 at 19:15 (7:15 PM) revealed she arrived by EMS/ambulance presented with altered mental status (AMS)- moderate, confusion and fever. Patient presented to the ED via EMS after a syncopal episode. She was found on the floor in the bathroom.

Medical history included seizures, gout, hypothyroid, and Hyperlipidemia (HLD).

Medical Decision Differential Diagnosis: Confusion, UTI, AMS.

Physician Orders included:
Cardiac monitoring and Oxygen therapy.
Radiology Orders: EKG, CT Head, CT Spine, XR Abdomen, XR Chest (1 view frontal).
Laboratory Orders: Auto Diff, B Type Natriuretic Peptide, CBC with Diff, CK, CMP, Magnesium Level, PT INR, PTT, Troponin I, Arterial Blood Gas, C Blood, Lactic Acid level, Mg, Procalcitonin, UA Microscopic, and Drug screen urine.
Medication Orders: Zofran 4mg IV Push once, and Morphine 2mg IV Push once.

Physician's Impression and Plan included the following diagnosis:
Rhabdomyolysis (break down of damaged skeletal muscle causing the release of myoglobin into the bloodstream which could lead to kidney damage),
UTI,
Leukocytosis (increased in white blood cells),
Community acquired pneumonia,
Hypokalemia (low potassium in the blood),
Septic shock (life-threatening infection causing organ failure and dangerously low blood pressure),
Mental Retardation, and
Metabolic encephalopathy (chemical imbalance in the blood; problem in the brain).

Plan to admit. Condition: Stable and Guarded.

Review of the Blood laboratory dated 1/26/19 at 20:13 revealed the following abnormalities:
White Blood Count (18.3 x10e3/mcL; High)
Red Blood count (3.53 x10e6/mcL; Low)
Hgb (11.80 gm/dL; Low)
Hct (35.80 %; Low)
MCV (101.6 Femtoliters; High)
MCH (33.60 pg; High)
Plt (108 x10e3/mcL; Low)
Segs Man (83 %; High)
Lmphs Man (5 %; Low)
Segs # Man (15 x10e3/mcL; High)
Lymphs # Man (0.9 x10e3/mcL; Low)
Aniso (1+)
Micro (1+)
Plt Est (Decreased)
Potassium (3.4 mmol/L; Low)
Chloride (111 mmol/L; High)
CO2 (20.9 mmol/L; Low)
BUN (37 mg/dL; High)
BUN/Creat Ratio (30.58 Ratio; High)
Albumin Level (2.5 gm/dL; Low)
TP (6.2 gm/dL; Low)
A/G Ratio (0.7 Ratio;Low)
AST (551 Intl_ units/L; High)
ALT (136 units/L; High)
CK (11,683 units/L CRITICAL)
BNP (248.7 pg/mL; High)

Review of the Chest X-Ray dated 1/26/19 at 20:31 revealed the following impression: Hypoaeration of the lungs is evident, with suggestion of mild basilar pulmonary atelectasis/pneumonic infiltrates more evident on the right, and with the differential diagnosis including pulmonary edema.

Review of the UA lab results dated 1/26/19 at 21:15 revealed the following abnormalities:
UA- Urine Color (Amber),
Positive for Protein (100mg/dL ++),
Ketones (trace),
Urobilinogen (2.0 Ehrl units/dL),
Blood (>=1.0 mg/dL Lg),
White Blood Count (10-14) and
Bacteria (2+).

Review of the facility's EMTALA Policy/Procedure for Medical Screening, Stabilization and Transfer, last revised 1/1/2018 indicated the following, in part:
4. The MSE consists of the following, as appropriate: "c. Results of any testing necessary to rule out the presence of a legally defined EMC."
5. Hospital will use any necessary ancillary services, such as laboratory and radiology, routinely available to the ED to conduct the MSE.

During an interview on 7/25/19 at 12:15 PM with the facility's Medical Director (MD) Physician stated the following after review of Patient #1's ED medical record dated 1/25/19 at 22:29:
Patient #1 presented with whole body aches, fever and Tachycardiac; breathing okay and it was flu season.
He stated the ED Physician-A ordered a chest x-ray, throat culture, UA, and flu test. Patient was treated with Motrin and IV fluids. UA results were not concerning. Blood pressure parameters acceptable without significant change. The Physician stated the Chest X-ray was normal; but that "early pneumonia would not show up." There was no respiratory distress.
The MD Physician further stated since this patient was "older, Tachycardiac, mental decompensated;" there was "room for blood work with this patient; should have gotten bloodwork."
The MD Physician reviewed Patient #1's second ED medical record along with the blood level laboratory results dated 1/26/19 at 20:13 (as documented above) stating; "this Patient was septic."

According to the Center for Disease Control at https://www.cdc.gov/sepsis/signs-symptoms
The signs for sepsis included: fever and high heart rate.
The symptoms for sepsis included: Confusion or disorientation, Extreme pain or discomfort, and Clammy or sweaty skin
Diagnosis includes: blood lab tests that check for signs of infection or organ damage; imaging tests, and other lab tests such as UA.