HospitalInspections.org

1. Based on review of hospital policy and procedures, medical records, and physician and staff interviews, the hospital failed to ensure a medical screening examination (MSE) was provided, within the capability of the hospital's Dedicated Emergency Department (DED), to determine whether an emergency medical condition existed for one (1) of 23 sampled DED patients (Patient #3). Refer to findings in Tag A-2406.


2. Based on a review of hospital policy, medical records and interviews, the hospital failed to provide stabilizing treatment 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 1 of 23 DED records reviewed (Patient #3). Refer to findings in Tag A-2407.

Based on review of hospital policy and procedures, medical records, and physician and staff interviews, the hospital failed to ensure a medical screening examination (MSE) was provided, within the capability of the hospital's Dedicated Emergency Department (DED), to determine whether an emergency medical condition existed for one (1) of 23 sampled DED patients (Patient #3).

The findings included:

Review of the policy titled "EMTALA (Emergency Medical Treatment and Labor Act) - Definitions and General Requirements, effective 09/01/2019, revealed "...The hospital ....must provide to any individual ....who 'comes to the emergency department' an appropriate Medical Screening Examination ....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 .... exists. ..."

1. The DED medical record revealed Patient #3 arrived via EMS (Emergency Medical Services) on 08/22/2022 at 0459. Review of the Triage Note, at 0504, documented an acuity [general level of patient illness, urgency for clinical intervention] of 2 - emergent [Requires immediate nursing assessment and rapid treatment]. The patient's vital signs were noted as heart rate 52 [Normal heart rate 60-100], respiratory rate 16, blood pressure 114/55 and oxygen saturation of 98% on 2 liters oxygen with a pain score of 0, no pain.

Review of the ED Provider Note, documented by Medical Doctor (MD) #2, revealed " ...Patient is a 100-year-old male with past medical history of hypertension, diabetes, dementia who presents from the (Long Term Care [LTC] facility) after having reported bright red gelatinous blood per rectum this evening. He also reportedly had coughed up some sputum that was blood-tinged as well ... Physical Exam [examination] .... Gastrointestinal: Abdomen is soft, and non-tender. Rectal exam: .... brown/yellow stool, no gross blood seen.... Assessment/Plan .... I will check labs, EKG (electrocardiogram- test used to evaluate the heart), chest x-ray, hydrate with normal saline, will start Protonix (can treat reflux disease, decreases the amount of acid in the stomach) and will reassess.... Reexamination /Reevaluation 08/22/22 at 0647 work up reviewed patient is on Plavix (blood thinner) with GI (gastrointestinal bleed) bleed... patient will be signed out to.... oncoming physician to follow-up with oncoming hospitalist regarding admission versus transfer. Diagnosis/Disposition GI bleed, hemoptysis (coughing up blood)..."

Review of a Provider Note by MD #1, signed at 0844 revealed "...presented last night .... with concern for 'blood-tinged sputum,' and 'red gelatinous blood per rectum.' He is not on any blood thinners. Normal blood pressure. Denies abdominal pain. Rectal exam by overnight physician with yellowish stool which was Hemoccult positive [positive for Blood detected in a stool sample] .... I spoke with his (relative), this morning .... gave me the additional information that this patient was admitted to the (name of outside hospital) .... for a 'bowel blockage.' .... He is not having any ongoing bleeding here or cough or hemoptysis. I examined the patient this morning ...His abdomen is soft although he says he has some mild discomfort when I push. No other significant findings on his exam .... Given his recent blockage, despite the absence of significant symptoms, I think we are obliged to move forward with CT imaging. If his imaging is okay, this patient may not require hospitalization and certainly I do not think he is a good candidate for invasive or aggressive interventions."

Review of an Addendum by MD #1 at 0928 revealed "1. Sigmoid colitis [Inflammation of the colon]; differential considerations include acute sigmoid diverticulitis versus ischemic/infectious/inflammatory processes (specifically, in light of severe diffuse atherosclerotic plaque, recommend correlation with lactate [lactate test may be used as part of an initial evaluation of someone who is suspected of having sepsis [it is a life threatening medical emergency, a serious condition in which the body responds improperly to an infection ...His LFTs [Liver Function Test] today look fine. His lactate is okay...." Record review revealed Patient #3 was discharged back to the LTC facility with a prescription for Augmentin to be taken orally every 12 hours for 10 days.

2. The medical record revealed Patient #3 returned by EMS to the DED on 09/05/2022 at 0921. Review of a Provider Note, service time 0938, revealed "...presents from nursing home with breathing difficulty.... Patient was seen here on August 31 after mechanical fall with reassuring labs and imaging .... He tells me he is having chest pain ....it appears he recently finished a course of Augmentin 'for colitis.' ... DNR [Do Not Resuscitate]. He was seen here August 22 and had a CT scan of the abdomen and pelvis which showed sigmoid colitis and possible cholecystitis. Prior to this visit he had been in the (outside hospital) for 'bowel blockage.' They thought there was 'something wrong with his gallbladder,' but no more details .... Assessment/Plan ill appearing .... increased work of breathing.... Reexamination/Reevaluation .... I ordered a CT angio of the chest to assess for other true trunk injuries and rule out pulmonary embolism, but also CT abdomen/pelvis .... Findings consistent with acute mesenteric ischemia involving the ileum and portions of the jejunum ...Obviously concerning findings as above, his discomfort and elevated Lactate certainly fit with a diagnosis of mesenteric ischemia. I have contacted the (outside hospital).... I updated his (relative) ....at 12:30 PM and updated her with the situation and my opinion of the very poor prognosis.... Spoke with patient's (relative) once again .... While I was on the phone with her, patient's heart rate dropped down to 0. Based on patient's DNR, he was allowed to peacefully expire. Time of death 1304 ...."

3. Interview with MD #1, on 07/17/2023 at 1500, revealed MD #1 recalled Patient #3 "very clearly". MD #1 stated he saw that he wrote the Lactate level was ok but during review of the record he did not see a Lactate result for the visit. Interview revealed colitis had a "big differential" and you "worry most" about mesenteric ischemia, which was what Patient #3 ultimately had upon return on 09/05/2023. MD #1 stated that Lactate was a marker related to ischemic bowel. During review of the medical record, there was no documentation of a physician's order for a Lactate level as recommended by the Radiologist for Patient #3 on the 08/22/2022.

Based on a review of hospital policy, medical record review and interviews, the hospital failed to provide stabilizing treatment 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 1 of 23 DED records reviewed (Patient #3).

The findings included:

Review of the policy titled "EMTALA (Emergency Medical Treatment and Labor Act) - Definitions and General Requirements, effective 09/01/2019, revealed "...POLICY....If an EMC is determined to exist, the hospital must provide either: (i) further medical examination and any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital; or (ii) an appropriate transfer to another medical facility. ..."

The DED medical record revealed Patient #3 arrived via EMS (Emergency Medical Services) on 08/22/2022 at 0459. Review of the Triage Note at 0504 documented an acuity of 2 - emergent. Review revealed a Provider Note, signed at 0844 which indicated "...presented last night .... with concern for 'blood-tinged sputum,' and 'red gelatinous blood per rectum ....' Rectal exam by overnight physician with yellowish stool which was Hemoccult positive.... I spoke with his (relative), this morning .... gave me the additional information that this patient was admitted to the (name of outside hospital) .... for a 'bowel blockage.' .... Given his recent blockage, despite the absence of significant symptoms, I think we are obliged to move forward with CT imaging. ..."

Review of Electronic Physician Orders for "CT (Computed Tomography) Abd [abdomen]/Pelvis W[with] Contrast (CT ABD/Pelvis w/IV (Intravenous) Contrast) dated 8/22/22 at 0829 revealed the Radiologic diagnostic study was ordered "STAT" by Physician A.

The Computed Tomography, dated 8/22/2022 of 8:49 AM, was reviewed. The "ABDOMEN/PELVIS FINDINGS:" revealed in part ... GALLBLADDER: Inflammatory changed are noted regionally. BILE DUCTS: Left intrahepatic pneumobilia [presence of air within the biliary system, perceived as a serious intra-abdominal pathology and required surgery]. As well as mild pneumobilia along the common bile duct ....IMPRESSION: Sigmoid Colitis differential considerations include sigmoid diverticulitis versus ischemic/infectious/inflammatory processes (specifically, in light of sever diffuse atherosclerotic plaque, recommend correlations with lactate) [The lactate test may be used as part of an initial evaluation of someone who is suspected of having sepsis [it is a life threatening medical emergency, a serious condition in which the body responds improperly to an infection]. 2. Possible acute cholecystitis [inflammation of the gallbladder]; recommend right quadrant ultrasound for better assessment. 3 Nonspecific pneumobilia without benefit biliary duct dilation; correlate with LFTs, for history of iatrogenic [induced unintentionally by a physician, or surgeon or by medical treatment] procedure, etc."

The hospital failed to provide further evaluation and any necessary stabilizing treatment, within the capabilities of the staff and facilities available at the hospital, for Patient #3 identified emergency medical condition. There was no documentation that a Lactate level was ordered, there were no Lactate level results found, and there was no order for a right quadrant ultrasound as recommended by the Radiologist.

Interview with MD #1, on 07/17/2023 at 1500, revealed MD #1 recalled Patient #3. MD #1 stated he saw that he wrote the Lactate level was ok but during review of the record he did not see a Lactate result for the visit. Interview revealed colitis had a "big differential" and you "worry most" about mesenteric ischemia, which was what Patient #3 ultimately had upon return on 09/05/2023. MD #1 stated that Lactate was a marker related to ischemic bowel.