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Based on document review and interviews, it was determined that in 1 of 22 (Pt. #1) ED records reviewed, the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure the patient received a complete medical screening, including ordered tests, in order to determine whether or not an emergency medical condition existed. Refer to citation at A 2406.

2. The Hospital failed to ensure the patient who presented with an emergency medical condition, received stabilizing treatment. Refer to citation at A 2407.

Based on document review and interview it was determined, for 1 of 22 (Pt. #1) ED clinical records reviewed, the Hospital failed to ensure the patient received a complete medical screening, including ordered tests, in order to determine whether or not an emergency medical condition existed.

Findings include:

1. The clinical record for Pt. #1, reviewed on 12/17/12 at approximately 12:40 P.M. included that this was a 55-year old female who arrived in the Emergency Department (ED) on 10/24/12 via Chicago Fire Department (CFD) Ambulance. The record noted that Pt. #1 presented with a chief complaints of nausea, vomiting, and diarrhea for seven days. The record included a "Physicians Progress Note and Order Sheet" dated 10/24/12 included the following: "CC: Nausea/Vomiting Vitals: HR 99 BP 93/54 R 20 T 97.9 SaO2 100%... Brought in by CFD... Accucheck High ...Seen by ED MD 8:10 P.M." The required RN signature for this section of the progress note was lacking. The Physician's Progress Note and Order Sheet included the following orders: CBC, chem, urinalysis, cardiac enzymes, ECG, portable CXR, 1000 cc 0.9 normal saline- wide open [rate], Regular insulin, Pepcid, and Zofran.

The "Emergency Physician Record- Nausea, Vomiting, Diarrhea," dated 10/24/12 at 8:35 P.M., noted a review of the systems including that the Cardiovascular (CVS) and Gastrointestinal (GI) systems were normal. The clinical impression was documented as
"Vomiting". There were no documented results of the ordered labs/tests, nor documentation that Pt. #1 received any of the ordered treatments.

The record included a form entitled, "Patient Leaving Hospital Against Medical Advice" dated October 24, 2012 at 9:00 P.M. The form lacked documentation of the attending physician's name (person to be released from all responsibility) and lacked Pt. #1's signature. The form included: "requested to sign AMA. Dressed self for climate, refused to sign form & left ED" The form was witnessed by E#4 (RN assigned to Pt. #1 on the evening of 10/24/12).

2. In a telephone interview on 12/18/12 at approximately 9:20 A.M., with E#2 (the ED physician on duty 10/24/12 7 P.M.-7 A.M.), E#2 stated that he did not remember Pt. #1, but that if a patient wants to leave AMA (against medical advice), the nurse usually informs him and he goes to see the patient to confirm that the patient wants to sign out AMA, and finds out the reason. E#2 also stated that he would document that he talked to the patient regarding the risks of signing out AMA, but that the patient can sign out AMA. if he/she is competent. The record of Pt. #1 did not include documentation that E#2 explained the risks to Pt. #1, of signing out AMA.

A telephone interview was conducted 12/18/12 at approximately 11:37 A.M., with E#3 (Charge/Triage Nurse) on the evening shift of 10/24/12. E#3 stated that she did not recall Pt. #1, and did not know why the triage was not completed for Pt. #1. However, E#3 stated that if the patient goes straight to the bed, the nurse who will be caring for that patient will do the triage, if the triage nurse is busy.

A telephone interview was conducted 12/18/12 at approximately 12:07 P.M., with E#4 (ED Nurse assigned to Pt.#1 on the evening shift of 10/24/12). E#4 stated that she did not remember Pt. #1 and was unable to explain why the triage assessment was not completed, but whenever she gets a patient signing out AMA, she notifies the nursing supervisor, the attending physician, and fills out an AMA form. Pt. #1's record lacked documentation that the physician or nursing supervisor was notified that Pt. #1 was leaving the Hospital AMA.

A telephone interview was conducted 12/20/12 at approximately 8:54 A.M., with E#8 (Nursing House Supervisor on the evening of 10/24/12). E#8 stated that she did not have any recollection, notification, or documentation of a patient signing out AMA from the ED on 10/24/12.

In an interview with the Ombudsman (E#5), on 12/18/12 at approximately 12:50 P.M., stated she talked to a patient the next morning after the incident that occurred on 10/24/12. E#5 stated the following: The patient (unnamed) witnessed a nurse refuse to help a patient, who was asking for help, up from the floor. That patient (needing help) was yelling for assistance, and then fell to the floor. The patient ' s nurse was telling the charge nurse not to help her up. E#5 stated that she spoke to the ED Manager, but did not get a name of the staff nurse. E#5 further stated she asked the patient (witness) to give a description, and the patient (witness) said the nurse had braids and was black.

E#1 (Senior Vice President of Patient Care Services), interviewed on 12/18/12 at 10:55 A.M. stated that E#4 had been terminated from service in November 2012, subsequent to multiple complaints, from patients and coworkers, about her performance. E#1 said E#4 admitted knowledge of all of the incidents (complaints), but said they did not occur in the manner that others described. E#1 further acknowledged that one of the complaints occurred on 10/24/12, and E#4 was the only one working in the ED on 10/24/12 that fit the description of the nurse, given by the patient (witness).

3. E#4's personnel file contained documentation of an incident of October 24, 2012 submitted by the Ombudsman on 10/25/12 from another patient who was in the ED on the evening of 10/24/12 and included: "Lady left at 8:59. Patient had been asking for help. No one came to help her. Pt. got out of bed, fell to the floor, and then nurse came and said get up off the floor. Lady stated I need help. Nurse told other nurses to leave her. She said you'll just lay there. No one is going to pick you up. Lady kept saying I've got chest pain, and they walked by her as if she was not there ... She begged for assistance to get help to take her clothes off ... no one came to help her while I was there ...the lady left and said I'll go somewhere I can get some help."

4. On 12/18/12 at 10:20 A.M. a telephone interview was conducted with Pt. #1 and the following was relayed: Pt#1 stated that she arrived at the Hospital by ambulance on 10/24/12 and the ambulance crew took her into the ED and put her on the bed. The nurse (name unknown) told Pt. #1 to take off her clothes and put on a gown, and they would take care of her. Pt. #1 said she couldn't do that because she was too weak, and could she get some help. Pt. #1 stated that the nurse said "no, if you can't do that, you have to leave. " Pt. #1 one said that that she tried to speak with the doctor, but the doctor never came over to see the patient. Pt. #1 denied that the doctor ever examined her or came to talk to her while she was there in the ED. Pt. #1 stated that since they wouldn't help her, she tried to leave, but fell to the floor. The patient said that the nurse and a male came and put her in a wheelchair, wheeled her out to the parking lot, and took the wheelchair back inside. The patient said she took the bus a distance, called for an ambulance from the bus stop, and the ambulance took Pt. #1 to Hospital B.

5. Pt. #1's clinical record from Hospital B included that the patient arrived at the ED of Hospital B via ambulance on 10/24/12 at 11:30 P.M., was triaged as urgent, had a blood glucose of 1066, and was admitted to the ICU.

Based on document review and interview it was determined, for 1 of 22 (Pt. #1) ED clinical records reviewed, the Hospital failed to ensure the patient who presented with an emergency medical condition, received stabilizing treatment.

Findings include:

1. The clinical record for Pt. #1, reviewed on 12/17/12 at approximately 12:40 P.M. included that this was a 55-year old female who arrived in the Emergency Department (ED) on 10/24/12 via Chicago Fire Department (CFD) Ambulance. The record noted that Pt. #1 presented with a chief complaints of nausea, vomiting, and diarrhea for seven days. The record included a "Physicians Progress Note and Order Sheet" dated 10/24/12 included the following: "CC: Nausea/Vomiting Vitals: HR 99 BP 93/54 R 20 T 97.9 SaO2 100%... Brought in by CFD... Accucheck High ...Seen by ED MD 8:10 P.M." The required RN signature for this section of the progress note was lacking. The Physician's Progress Note and Order Sheet included the following orders: CBC, chem, urinalysis, cardiac enzymes, ECG, portable CXR, 1000 cc 0.9 normal saline- wide open [rate], Regular insulin, Pepcid, and Zofran.

The "Emergency Physician Record- Nausea, Vomiting, Diarrhea," dated 10/24/12 at 8:35 P.M., noted a review of the systems including that the Cardiovascular (CVS) and Gastrointestinal (GI) systems were normal. The clinical impression was documented as
"Vomiting". There were no documented results of the ordered labs/tests, nor documentation that Pt. #1 received any of the ordered treatments.

The record included a form entitled, "Patient Leaving Hospital Against Medical Advice" dated October 24, 2012 at 9:00 P.M. The form lacked documentation of the attending physician's name (person to be released from all responsibility) and lacked Pt. #1's signature. The form included: "requested to sign AMA. Dressed self for climate, refused to sign form & left ED" The form was witnessed by E#4 (RN assigned to Pt. #1 on the evening of 10/24/12).

2. In a telephone interview on 12/18/12 at approximately 9:20 A.M., with E#2 (the ED physician on duty 10/24/12 7 P.M.-7 A.M.), E#2 stated that he did not remember Pt. #1, but that the patient did not want anything done. E#2 stated that he arrived at this conclusion because there was an AMA form in the patient's record. The record of Pt. #1 did not include documentation that E#2 explained the risks to Pt. #1, of signing out AMA.

A telephone interview was conducted 12/18/12 at approximately 12:07 P.M., with E#4 (ED Nurse assigned to Pt.#1 on the evening shift of 10/24/12). E#4 stated that she did not remember Pt. #1 and was unable to explain why the triage assessment was not completed, but whenever she gets a patient signing out AMA, she notifies the nursing supervisor, the attending physician, and fills out an AMA form. Pt. #1's record lacked documentation that the physician or nursing supervisor was notified that Pt. #1 was leaving the Hospital AMA.

A telephone interview was conducted 12/20/12 at approximately 8:54 A.M., with E#8 (Nursing House Supervisor on the evening of 10/24/12). E#8 stated that she did not have any recollection, notification, or documentation of a patient signing out AMA from the ED on 10/24/12.

In an interview with the Ombudsman (E#5), on 12/18/12 at approximately 12:50 P.M., stated she talked to a patient the next morning after the incident that occurred on 10/24/12. E#5 stated the following: The patient (unnamed) witnessed a nurse refuse to help a patient, who was asking for help, up from the floor. That patient (needing help) was yelling for assistance, and then fell to the floor. The patient ' s nurse was telling the charge nurse not to help her up. E#5 stated that she spoke to the ED Manager, but did not get a name of the staff nurse. E#5 further stated she asked the patient (witness) to give a description, and the patient (witness) said the nurse had braids and was black.

E#1 (Senior Vice President of Patient Care Services), interviewed on 12/18/12 at 10:55 A.M. stated that E#4 had been terminated from service in November 2012, subsequent to multiple complaints, from patients and coworkers, about her performance. E#1 said E#4 admitted knowledge of all of the incidents (complaints), but said they did not occur in the manner that others described. E#1 further acknowledged that one of the complaints occurred on 10/24/12, and E#4 was the only one working in the ED on 10/24/12 that fit the description of the nurse, given by the patient (witness).

3. E#4's personnel file contained documentation of an incident of October 24, 2012 submitted by the Ombudsman on 10/25/12 from another patient who was in the ED on the evening of 10/24/12 and included: "Lady left at 8:59. Patient had been asking for help. No one came to help her. Pt. got out of bed, fell to the floor, and then nurse came and said get up off the floor. Lady stated I need help. Nurse told other nurses to leave her. She said you'll just lay there. No one is going to pick you up. Lady kept saying I've got chest pain, and they walked by her as if she was not there ... She begged for assistance to get help to take her clothes off ... no one came to help her while I was there ...the lady left and said I'll go somewhere I can get some help."

4. On 12/18/12 at 10:20 A.M. a telephone interview was conducted with Pt. #1 and the following was relayed: Pt#1 stated that she arrived at the Hospital by ambulance on 10/24/12 and the ambulance crew took her into the ED and put her on the bed. The nurse (name unknown) told Pt. #1 to take off her clothes and put on a gown, and they would take care of her. Pt. #1 said she couldn't do that because she was too weak, and could she get some help. Pt. #1 stated that the nurse said "no, if you can't do that, you have to leave. " Pt. #1 one said that that she tried to speak with the doctor, but the doctor never came over to see the patient. Pt. #1 denied that the doctor ever examined her or came to talk to her while she was there in the ED. Pt. #1 stated that since they wouldn't help her, she tried to leave, but fell to the floor. The patient said that the nurse and a male came and put her in a wheelchair, wheeled her out to the parking lot, and took the wheelchair back inside. The patient said she took the bus a distance, called for an ambulance from the bus stop, and the ambulance took Pt. #1 to Hospital B.

5. Pt. #1's clinical record from Hospital B included that the patient arrived at the ED of Hospital B via ambulance on 10/24/12 at 11:30 P.M., was triaged as urgent, had a blood glucose of 1066, and was admitted to the ICU.