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Based on medical record review, policy review, and staff interviews, the hospital failed to follow their policy to provide stabilizing treatment within the hospital's capability for 1 of 40 sampled patients (Patient # 26). The hospital had an average of 1051 patients presenting to the emergency department (ED) and requesting care monthly.

Failure to provide appropriate stabilizing treatment resulted in the patient's discharge and the patient returned to the hospital's ED 2 hours later for further care, including admission to the hospital and surgery.

Findings include:

1. Review of Patient #25's medical record revealed a 20 year old patient arrived in the ED on 4/14/14 at 11:06 PM with complaint of abdominal pain of 4 - 5 duration. ED Physician A ordered labs and x-rays of the patient's abdomen. The lab results were within normal limits and the abdominal x-ray preliminary report revealed no bowel obstruction or free air but showed moderate retained stool, possibly reflecting constipation. The patient was discharged to home on 4/15/14 at 12:55 AM with a diagnosis of constipation documented by Physician A.

a. Patient #25, now patient #26, returned to the ED on 4/15/14 at 3:08 PM with complaint of intermittent sharp, crampy abdominal pain. ED Physician B documented the patient had moderate abdominal pain, the patient rated a 7 on a scale of 10 being the worst pain the patient had. ED Physician B ordered labs, CT of the abdomen, and medication for pain and nausea. The lab results revealed elevated liver tests including an elevated bilirubin of 3.0 [normal level 0.2 - 1.0]. The abdominal CT preliminary report revealed may reflect cholelithiasis [indication of the presence of gallstones]. The patient was discharged to home on 4/15/14 at 7:00 PM. ED Physician B documented clinical impression as abdominal pain - acute, elevated liver function tests.

b. Patient #25, now patient #27, returned to the ED on 4/15/14 at 9:04 PM, 2 hours later, with complaint of worsened abdominal pain and can't breath or move. Patient reported to the ED staff he started feeling better after the pain shot he received when in the ED earlier. The patient stated he was walking home and the pain became more severe when walking and mild nausea. ED physician C documented the patient had diffuse abdominal tenderness and admitted the patient to observation on 4/15/14 at 11:30 PM. Patient #27 was found to have acute cholecystitis on ultrasound. The patient had surgery for removal of his gallbladder and attempted common bile duct exploration on 4/16/14. Surgery revealed four gallstones ranging from 0.4 to 1.0 cm in diameter. The patient recovered and was discharged from the hospital on 4/19/14.

2. The hospital's policy titled "COBRA/EMTALA POLICY", dated May 24, 1999, revealed the following, in part, ". . . All patients presenting themselves to Keokuk Area Hospital for emergency care shall be treated in a medically appropriate manner and such care and/or transfer to another facility shall not be predicated upon arbitrary, capricious, or discriminatory practices. . . . "

The hospital's policy titled "Transfer of Patients/Emergent and Non-Emergent", dated 2/2012, revealed the following, in part, ". . . When an individual presents to the emergency department of the Hospital and a request is made on the individual's behalf for a medical screening examination or treatment, an appropriate medical screening examination, within the capabilities of the emergency department (including ancillary services routinely available to the emergency department), shall be provided to determine whether an emergency condition exists. . . . "

3. During an interview on 10/22/14 at 7:35 AM, Physician A, Interim ED Medical Director, reviewed medical record for Patient #25 (also #26 and 27 - second and third ED visit). Physician A stated the patient had definite changes in the patient's second ED visit [4/15/14 at 3:08 PM]. Physician A stated the patient's liver function tests were pretty high on the patient's second ED visit and probably would have been appropriate for the patient to have been placed on observation during the second ED visit to see how the patient's liver function progressed.

During an interview on 10/24/14 at 8:00 PM, ED Physician B stated Patient #26 had diffuse abdominal pain, was not in the patient's right upper quadrant, and elevated liver function tests, but not his bilirubin, during his 4/15/14 3:08 PM ED visit but were not elevated the previous night when the patient was in the ED. Physician B stated he ordered a hepatitis profile which was pending at the time he discharged the patient. Physician B thought the patient had hepatitis and discharged the patient to home.

Based on medical record review, policy review, and staff interviews, the hospital failed to provide stabilizing treatment within the hospital's capability for 1 of 40 sampled patients (Patient # 26). The hospital had an average of 1051 patients presenting to the emergency department (ED) and requesting care monthly.

Failure to provide appropriate stabilizing treatment resulted in the patient's discharge and the patient returned to the hospital's ED 2 hours later for further care, including admission to the hospital and surgery.

Findings include:

1. Review of Patient #25's medical record revealed the 20 year old patient arrived in the ED on 4/14/14 at 11:06 PM with complaint of abdominal pain of 4 - 5 duration. ED Physician A ordered labs and x-rays of the patient's abdomen. The lab results were within normal limits and the abdominal x-ray preliminary report revealed no bowel obstruction or free air but showed moderate retained stool, possibly reflecting constipation. The patient was discharged to home on 4/15/14 at 12:55 AM with a diagnosis of constipation documented by Physician A.

a. Patient #25, now patient #26, returned to the ED on 4/15/14 at 3:08 PM with complaint of intermittent sharp, crampy abdominal pain. ED Physician B documented the patient had moderate abdominal pain, the patient rated the pain as a 7 on a scale of 10 being the worst pain the patient had. ED Physician B ordered labs, CT of the abdomen, and medication for pain and nausea. The lab results revealed elevated liver tests including an elevated bilirubin of 3.0 [normal level 0.2 - 1.0]. The abdominal CT preliminary report revealed may reflect cholelithiasis [an indication of the presence of gallstones]. The patient was discharged to home on 4/15/14 at 7:00 PM. ED Physician B documented clinical impression as abdominal pain - acute, elevated liver function tests.

b. Patient #25, now patient #27, returned to the ED on 4/15/14 at 9:04 PM, 2 hours later, with complaint of worsened abdominal pain and can't breath or move. Patient reported to the ED staff he started feeling better after the pain shot he received when in the ED earlier. The patient stated he was walking home and the pain became more severe when walking and mild nausea. ED physician C documented the patient had diffuse abdominal tenderness and admitted the patient to observation on 4/15/14 at 11:30 PM. Patient #27 was found to have acute cholecystitis on ultrasound. The patient had surgery for removal of his gallbladder and attempted common bile duct exploration on 4/16/14. Surgery revealed four gallstones ranging from 0.4 to 1.0 cm in diameter. The patient recovered and was discharged from the hospital on 4/19/14.

2. The hospital's policy titled "Transfer of Patients/Emergent and Non-Emergent", dated 2/2012, revealed the following, in part, ". . . When an individual presents to the emergency department of the Hospital and a request is made on the individual's behalf for a medical screening examination or treatment, an appropriate medical screening examination, within the capabilities of the emergency department (including ancillary services routinely available to the emergency department), shall be provided to determine whether an emergency condition exists. . . . "

3. During an interview on 10/22/14 at 7:35 AM, Physician A, Interim ED Medical Director, reviewed medical record for Patient #25 (also #26 and 27 - second and third ED visit). Physician A stated the patient had definite changes in the patient's second ED visit [4/15/14 at 3:08 PM]. Physician A stated the patient's liver function tests were pretty high on the patient's second ED visit and it probably would have been appropriate for the patient to have been placed on observation during the second ED visit to see how the patient's liver function progressed.

During an interview on 10/24/14 at 8:00 PM, ED Physician B stated Patient #26 had diffuse abdominal pain, was not in the patient's right upper quadrant, and elevated liver function tests, but not his bilirubin, during his 4/15/14 3:08 PM ED visit but were not elevated the previous night when the patient was in the ED. Physician B stated he ordered a hepatitis profile which was pending at the time he discharged the patient. Physician B thought the patient had hepatitis and discharged the patient to home.