HospitalInspections.org

Based upon medical record review and interview, it was determined that the facility failed to have policies and procedures in effect to ensure compliance with 42 CFR 489.24 and the related provisions at 42 CFR 489.20.

Findings include:

Medical record review and interview revealed the facility did not comply with all of the provisions of a medical screening exam. Please reference findings under Tag A2406.

Based on medical record review and interview, Patient #1 was not provided with a medical screen examination in the emergency department (ED) to determine if an emergency medical condition (EMC) existed.

Findings include:

Medical record review revealed Patient #1 presented to the ED of the hospital on 2/28/13 at 6:09 PM with chief complaint of severe abdominal pain with nausea. She was triaged at an acuity level of 2 - emergent. She had a complicated history of abdominal issues, including several surgeries since 2011, with one as recent as January 2013.

ED attending physician documentation at 9:21 PM revealed the patient arrived with stabbing abdominal pain, non-radiating, with nausea. The abdomen appeared normal, with active bowel sounds and mild abdominal tenderness in all quadrants. There was a healing incisional wound mid-abdomen, with no surrounding erythema or drainage noted.

Results of Patient #1's CT scan of the abdomen and pelvis were reviewed by an ED attending physician at 10:19 PM. The impression was there was small bowel obstruction.

The consulting surgeon, Staff #14, saw the patient and wrote a discharge order at 10:00 PM. The patient wanted to go home for outpatient follow-up care. The surgeon gave the patient a prescription for Percocet and noted she had a follow-up appointment. Patient #1 was discharged to home ambulatory at 10:46 PM.

On 3/1/13 at 3:50 AM, Patient #1 returned to the ED with complaint of abdominal pain and vomiting. She was noted to be in severe distress secondary to nausea/vomiting and abdominal pain. Patient #1 was admitted to the hospital and had an exploratory laparotomy (abdominal surgical procedure) with pre-operative diagnosis of abdominal sepsis.

Interview of Surgeon Staff #14 on 10/30/13 at 11:25 AM revealed Patient #1 was known to him due to several years' history of abdominal issues. He stated he knew Patient #1 well, and if she had been clinically ill during her ED visit on 2/28/13, he would have admitted her. He said that Patient #1 was not clinically obstructed: her abdomen did not show signs and symptoms of obstruction, her white blood count was good, she did not have nausea or vomiting, her abdominal wound was clean without drainage. He stated he did not see the results for Patient #1's CT of the abdomen.

There was no evidence in the 2/28/13 ED medical record that the results of Patient #1's CT scan of the abdomen and pelvis were communicated between the ED attending who reviewed it, and the consulting surgeon who discharged her.