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33394

Based on staff interview, family interview, patient interview, emergency room record review, review of the police report, review of police dash cam video, and review of policies and procedures, the hospital failed to comply with 489.24, Special responsibilities of Medicare hospitals in emergency cases, for 2 of 24 sampled patients (#10, and #23) that presented to the emergency department. The hospital failed to provide an appropriate Medical Screening Exam for patients #10 and #23 (see C2406); failed to provide an appropriate discharge for patient #10 (see C2409); and failed to obtain informed refusal for care for patient #23 (see C2407).

The findings include:

A. Based on hospital staff interviews, Emergency Medical Services (EMS) staff interview, family interview, patient interview, emergency department record review, reviews of the police report, and police dash cam video, review of the Ambulance services report, and review of facility policies and procedures, the hospital failed to provide an appropriate Medical Screening Exam (MSE) to determine the existence of an emergency medical condition for 2 of 24 sampled patients (#10, and #23) that presented to the emergency department (ED). The hospital failed to provide an appropriate MSE for patient #23 who complained of severe back pain. The hospital failed to provide an appropriate MSE for patient #10, while in the ED, patient #10 complained of shortness of breath numerous times. Patient #10 was discharged without having an appropriate MSE which addressed this complaint. Upon discharge, while still on hospital grounds, patient #10 collapsed in the hospital parking lot, and subsequently died. Refer to C2406.

B. Based on staff interview, patient interview, emergency room record review, and policy review, the hospital failed to explain risks and benefits of refusal and failed to take all reasonable steps to secure the individual's written informed refusal for 1 of 24 sampled patients (#23) who presented to the emergency department. Refer to C2407.

C. Based on reviews of emergency department medical records, policy and procedures, Police reports, dashcam video recording and interviews with family member and facility staff members, the facility failed to provide an appropriate discharge for 1 of 24 sampled patients,( #10) who was discharged with an unstabilized emergency medical condition while in the emergency department complained of shortness of breath on numerous occasions and collapsed in the hospital ' s parking lot and subsequently died in the hospital ' s emergency department. Refer to C2409.

Based on staff interviews, emergency medical services (EMS) staff interview, family interview, patient interview, emergency department record review, review of the police report and dash cam video, review of the Ambulance services report, and review of facility policies and procedures, the hospital failed to provide an appropriate Medical Screening Exam (MSE) to determine the existence of an emergency medical condition for 2 of 24 sampled patients (#10, and #23) that presented to the emergency department (ED). The hospital failed to provide an appropriate MSE for patient #23 who complained of severe back pain. The hospital failed to provide an appropriate MSE for patient #10, while in the ED, patient #10 complained of shortness of breath numerous times. Patient #10 was discharged without having an appropriate MSE which addressed this complaint. Upon discharge, while still on hospital grounds, patient #10 collapsed in the hospital parking lot, and subsequently died.

The findings include:

Patient #10:

The Patient Care Report Calhoun-Liberty Ambulance Services report dated 12/20/2015 at 10:00 P.M. was reviewed. The report revealed in part, "EMS (Emergency medical services) responded immediately to a 57 year old female patient (#10) complaining of hypertension. Upon EMS arrival pt (patient) was alert with a Glasgow coma scale (level of consciousness) of 15. Pt stated earlier that her blood pressure had been elevated since 6 PM the night before. She also stated that she had right upper quadrant pain X (times) 3 days." The paramedic did note the patient had a low oxygen saturation and "slightly labored breathing" , at which time the oxygen flow was increased from 2 liters per minute to 3. The patient's airway was noted to be patent with respirations of 20. Breath sounds were clear on both left and right. The oxygen saturation was 91% (measures level of oxygen found in a person's blood- normal Oxygen saturation level is 95% to 100%). "The patient's abdomen and lower extremities were assessed and no abnormalities were noted. Further review revealed, "cardiac monitor displayed sinus tachycardia (fast heartbeat) initial VS (vital signs) were pulse 135 (normal is 60-100), blood pressure 117/72, blood glucose 105." Documentation by the Paramedic also indicated that Intravenous access was attempted but the patient "adamantly refused." The paramedics documented Patient #10's "Primary Symptom" as pain and "Provider Impression: Abdominal pain/problem Provider Secondary Impression: Respiratory Distress." According to the report Patient #10 was transported by EMS to Calhoun-Liberty Hospital and was left in care of the ED, condition improved, and a verbal report was given to the primary medical doctor.

An emergency department clinical record review was conducted for patient #10. Patient #10 presented to the emergency department (ED) via ambulance on 12/20/15 at 10:10pm. Staff C, the ED paramedic, documented a verbal report received from EMS (emergency medical services) which stated the patient's chief complaint was hypertension (high blood pressure) and "talking out of her head." The patient was in "no acute distress" and was placed on oxygen NC (nasal cannula).

Staff C triaged (medical process in which patients are sorted according to the need for care) patient #10 at a triage level of "3-Urgent"on 12/20/15 at 10:26pm. The chief complaint recorded during triage was abdominal pain for 2 days which had not improved. The Triage nurse documented lung sounds were clear and equal, heart with normal sinus rhythm, and abdominal pain was located in the right and left lower quadrants of the abdomen, abdomen was soft and non-tender and active bowel sounds. The severity of the pain was 9 on a 1-10 pain scale (9-10 indicating excruciating pain). The first vital signs (12/20/2016 at 10:26 pm) in the ED were pulse (Heart rate) 72, respirations 24, Blood pressure 102/65, temperature 99, and an oxygen saturation of 90%. The patient was placed on oxygen per nasal cannula but the amount of oxygen that was administered while the patient was in the ED for her initial visit was not documented in the medical record. Review of the medical record (under "general assessment") indicated that patient was in"mild distress" "cooperative", "attentive" and "coherent" upon admission to the ER.

The physician conducted a MSE on 12/20/15 at 10:33pm. The physician documented "patient presents with left mid quadrant to left flank abdominal pain as well as suprapubic pain. States she feels very gassy and complains of ongoing chronic pain from uterine fibroids. She denies any chest pain, shortness of breath, palpitations, nausea, vomiting, diarrhea, fever or chills." The physician also notes that the patient has a history of Congestive Heart Failure and is on home oxygen. The physician documented under the section titled "Physical Examination" that lung sounds were clear and equal bilaterally. The patient's abdominal pain was documented as 7 (severe pain) on a pain scale of 1-10. The physician also documented the patient's abdomen was soft with mild tenderness. The physician documented in part, "Patient (#10) is verbally abusive to myself and staff. The" friends" that have accompanied her state that "she will often exaggerate about her many different symptoms". She is unwilling to cooperate during ED visit for adequate evaluation, at least initially, she did agree lab work and CT (Computerized scan) A/P (Abdomen/Pelvis)."

The physician ordered tests related to the abdominal pain to include a CT scan (computerized tomography) of the abdomen and pelvis and laboratory tests. Review of the results of the CT scan of the abdomen and pelvis dated 12/21/2015 revealed in part, "Findings: The study is suboptimal due to lack of contrast ...Abdomen: The aorta has trace atherosclerotic calcification (hardening of the arteries) throughout ...Pelvis: uterus is enlarged with numerous calcified leiomyoma (fibroid tumors usually found in the uterus). Impression: 1. Leiomyatous uterus. 2. Some pulmonary findings suggestive of pulmonary arterial hypertension. Clinical correlation is recommended." Review of the laboratory blood test ordered by the physician titled "Comprehensive Metabolic Panel" revealed in part, the patients Potassium L (low) 2.8 (Hospital reference range is 3.5-5.1); Carbon Dioxide 38.6 H (High)(Hospital reference range 21.0-32.0); Urea Nitrogen 29 H (hospital reference range 7-18); Creatinine 1.5 H (hospital reference range 0.6-1.3); and Glucose 169 H(Hospital reference range: 70-110).

Review of the medication orders verified that on 12/20/2015 the physician ordered oral pain medication "STAT' at 11:37 p.m. and the medication was administered to patient #10 at 12:16 a.m. on 12/21/2015. The physician also ordered Potassium Chloride tablet 20 meq (milli equivalent) on 12/21/2015 at 12:27 am, and the medication was administered to the patient at 1:20 am on 12/21/2015. The medical record failed to include a reassessment of the pain after receiving the pain medication.

Per the 'Vitals Report', a partial set of vital signs was taken on 12/21/15 at 12:15am and 2:36am. At 12:15am, Staff C documented a pulse of 64, a blood pressure of 109/71 and an oxygen saturation of 94%. At 2:36am, staff C documented a pulse of 67, a blood pressure of 107/62 and an oxygen saturation of 94%. No respiratory rate was documented during this time period. There was still no documentation as to the amount of oxygen patient #10 was on during this time.

The discharge order was written on 12/21/15 at 4:18am. The physician recommended that patient #10 have an outpatient work-up for the abdominal pain through her primary care physician. On 12/21/15 at 4:20am, Staff C, the ED paramedic, documented that he "went to discuss discharge with patient." He documented that patient #10 refused vital signs and refused to leave. Several staff and family members tried to reason with her, but the patient continued to refuse vital signs and refused to leave. The police department was called because Patient #10 refused to leave the emergency department.

Staff C documented that patient #10 ambulated (walked) out of the facility on 12/21/15 at 5:00am with a police officer. Staff C further wrote that "shortly thereafter" he was requested to go outside because patient #10 was on the ground and refusing to get in the police car.

Nurse A, the ED registered nurse, documented that on 12/21/15 at 5:07am she was called outside by the ED clerk and found patient #10 sitting on her knees on the ground with her hands cuffed behind her back. Patient #10 had an oxygen saturation of 98% and a pulse of 70. The patient was breathing equally and had palpable pulses. No further assessment was documented.

At 5:15am, Nurse A wrote that she returned to the parking lot to check on patient #10. The oxygen saturation remained 98% on room air, and her pulse was 70, "continues with equal breaths and palpable pulses. Due to patient not opening eyes this nurse returned to the ED at approximately 5:18am and called doctor to parking lot to assess patient." No other nursing assessment was documented.

Review of Progress Notes on 12/21/2015 "Addendum" revealed the physician documented that he was notified about 5:19am that his assistance was needed in the parking lot to evaluate a patient. "I was not aware that after patient had been discharged home that due to her behavior the police had been notified and were escorting patient off of premises." The physician wrote that he arrived in the parking lot to assess the patient at about 5:20am. The patient was on her knees on the ground next to the police car with ED nursing staff present. "On exam of patient, pulses were present, however she was not responding to verbal communication, therefore I had her immediately brought back into ED for evaluation."

The patient was placed on a stretcher and taken back into the ED where she went into cardiac arrest on 12/21/15 at 5:25am per review of the 'Code Blue Flow Sheet'. Advanced cardiac life support (Clinical algorithms used for the treatment of life threatening Cardiovascular conditions) protocols were immediately initiated. Resuscitative efforts continued until 6:20am, when patient #10 was pronounced dead.


Police Dash Cam:
On 1/14/15 at 8:30pm, the police dash cam video and audio recording was reviewed. The recording indicated that the police officer entered patient #10's room at 4:50am. The police officer informed the resident she had been discharged and requested that she leave the premises. Patient #10 could be heard requesting to stay in the ED, and stating multiple times, "I can't breathe" and "Help me" and complained she felt like she was going to die. Patient #10 sounded short of breath in the video. Her breathing was audible on the video. Patient #10 was also heard moaning and groaning on the Police Dash cam video prior to exiting the ED. The patient could be heard verbally until 4:59 am. The patient collapsed in the hospital's parking lot beside the police car. At 5:01am, the police officer requested medical staff to "check her real quick." A nurse could be heard stating her pulse is 70 and oxygen saturation is 98%. Patient #10 remained on the ground with the police and hospital staff in attendance until 5:20am when the ED physician then came an evaluated her. She was assisted onto a stretcher and returned to the emergency department.

Review of the clinical record revealed no documentation the physician had been notified of the patient change in condition of Patient #10 as she was leaving the ER and detained by the PO.

Police Report:
A record review of the police report submitted by the responding police officer was conducted. The police report states that the officer responded on 12/21/15 at approximately 4:46am "in reference to Patient #10 refusing to leave the premises." The report also revealed that the staff reported to the PO that patient #10 was "Ok and had been discharged." Review of this report indicated the PO explained to patient #10 that she had to leave the hospital at the request of the hospital staff. This report also revealed the patient reported to the PO "she still did not feel well and that she wanted more treatment." According to this Police report patient#10 was handcuffed in the ED and placed under arrest for "Disorderly Conduct and Trespassing." The report states that the police officer escorted Patient #10 to his patrol car, and once at the car, patient #10 began to fall to the ground. "Moments later medical staff arrived at my patrol car where patient #10 was lying ... As Myself and medical staff made several attempts to place patient #10 in my patrol car to no avail." I continued to ask patient #10 to comply with my request and get in the car, but patient #10 continued to be unresponsive to any commands or request. I then asked medical staff (nurse A) who is a nurse to check patient #10 vitals which she did." Further review of the report revealed in part,"Moments later a Doctor walked outside and checked Patient #10 vitals. After doing so, he stated that Patient #10 needed to be taken back inside the hospital ...He stated that she was being readmitted for symptoms totally different from what she had been released for earlier."

Interviews:
On 12/29/15 at approximately 8:35am, an interview was conducted with staff "C", the ED triage paramedic who had been assigned to patient #10. Staff C was asked about the missing documentation for respiratory rate. Staff C stated that the 'Vital Report' form is printed directly from the vital signs monitor onto the electronic record. Staff have to go back into the record to add the respiratory rate and oxygen amount. Staff C stated that during triage, all patients receive heart and lung assessment regardless of presenting symptoms. Staff C stated that patient #10's chief complaint was abdominal pain since Friday evening (2 days) and a high blood pressure. Her blood pressure was within normal limits on admission. While in the ED the patient visited with family members and walked around the room without oxygen. Patient #10 refused to accept the discharge summary, refused vital signs, refused to leave the facility and was acting in an aggressive manner, so law enforcement was called. They arrived around 4:45am on 12/21/15. Staff C stated that patient #10 had no objective signs of shortness of breath. Staff observed patient #10 actively resisting the officer while being led out of the building. Patient #10 continued to holler and be disruptive. Staff C stated that a patient experiencing respiratory distress and shortness of breath would not have had the reserve for the behaviors she was exhibiting. Patient #10 left the hospital at 5:00am. A staff member remained continuously with patient #10 after she went down. It was perceived to be further resistance of arrest as vital signs were within normal parameters. Another nurse checked her oxygen saturation, heart rate and respirations. The physician was summoned to the parking lot at approximately 5:18am.


On 12/29/15 at 10:15am an interview was conducted with staff member "A" who was the emergency department registered nurse at the time of the incident. Nurse A stated patient #10 had come to the emergency room for abdominal pain. The police department was called because she was refusing to leave the ED. Nurse A stated that she was summoned by the ED clerk to the parking lot to check on the patient after being told that the patient had collapsed. She checked a pulse which was 70 and the patient's oxygen saturation which was 98%. She did not believe a medical emergency existed at that point since vital signs were stable. She was under the impression that patient #10 was trying to get out of going to jail. Nurse A stated that the patient had shown no signs of distress when she exited the ED with the police officer and that the patient had been walking on her own, yelling and talking and had no discoloration. Nurse A stated that she assessed the patient twice while she was in a kneeling position beside the police cruiser and that the patient still had a pulse and respirations but was not responsive so she sought out the physician to examine the patient after the second time she checked her. Nurse A stated that the physician made the decision to return the patient to the ED.


On 12/29/15 at 11:08am an interview was conducted with the family member present with patient #10 when the incident occurred in the ED and the hospital's parking lot. The family member stated that cardiopulmonary resuscitation had not been initiated in the parking lot. She stated that she shook the patient and called her name but the patient never responded to her. She stated that she told the staff that they had "killed" the patient and was told by the nurse that the patient was fine. She stated that the patient did not want to leave the ED because she was having significant abdominal pain. She stated that the patient had been having trouble breathing the whole time she was in the ED.


On 12/29/15 at approximately 2:00pm an interview was conducted with staff member "B," a registered nurse who was present in the ED at the time of the incident. Nurse B stated that an officer and the primary ED nurse were attempting to get the patient to leave on her own accord. She stated that she informed the officer that the patient's oxygen tubing would have to be disconnected from the wall. Once the oxygen tubing was disconnected, it was dangling onto the floor, and nurse B stated that she was concerned that the tubing would cause her to trip, so nurse B cut the tubing at the patient's chest level. Nurse B stated that the patient did not require oxygen 24 hours a day and the patient was showing no signs of respiratory distress. The patient ambulated (walked) out with the police. After discharge, nurse B observed patient #10 on the ground. Nurse B stated she checked and the patient had an oxygen saturation of 98% and a pulse of 70. Patient #10 jerked her hand back, but was still able to place the pulse oximeter (measures oxygen saturation) on her finger. Nurse B stated she checked again two other times, on one occasion the oxygen saturation was 96% and pulse was 64. On the 3rd check, the pulse was slower, but the physician had already seen her.

An interview was conducted with the Director of Operations from the medical examiner's office on 12/30/15 at approximately 3:30pm. Per the representative, the preliminary cause of death was a pulmonary saddle embolism. (A saddle pulmonary embolism is a large blood clot in the lungs that straddles the arterial bifurcation and thus blocks both branches).


On 1/4/16 at 4:30pm a telephone interview was conducted with the physician present in the ED at the time of the incident with patient #10. He stated that the patient had presented and been worked up extensively for a complaint of abdominal pain. The physician stated that females often present with atypical cardiac symptoms, so he asks all females about cardiac or respiratory issues including shortness of breath. The physician stated that he spoke with EMS, and they did not report any respiratory issues. Patient #10 never reported chest pain or shortness of breath. He stated that several times during the stay, she took her oxygen off and walked around the room without it, and was yelling at times. The physician stated he visited with patient #10 a minimum of 4-5 times while she was in the ED. There were no signs of peripheral edema, no shortness of breath, and no signs of fluid overload. Patient #10 had a known history Congestive Heart Failure with intermittent supplemental oxygen use at home. The physician stated that he was never informed the patient was being arrested. The physician stated during interview that "Would have liked to have been aware that she (Patient #10) was discharged in police custody." When he was summoned to the parking lot, he did not know who he was going to assess. The physician stated that Patient #10 was assessed immediately when he was contacted. He stated he asked "What was going on." He stated that the pulse oximetry was on the patient's finger at 98% and her heart rate was in the 70's when he went outside. He continued to state that he was not aware of what had been done prior to his arrival. He stated that patient #10 was unconscious and was not responding to verbal stimuli. He also stated that he detected a radial and apical pulse, and auscultated for breath sounds with noted audible air exchange. He stated in part, "his experience with angry patients ...if spend more time and don't rush them out the door, patient satisfaction goes up." The physician stated that he was aware of the Medical Examiner's diagnosis of saddle pulmonary embolus, and stated that sinus tachycardia, and hypotension are significant precursors in saddle pulmonary emboli.


An interview was conducted at approximately 9 AM on 1/5/16 with EMS staff who transported patient #10 to the hospital from home. They stated the patient's blood pressure reading was taken and that it was normal. The patient had a pulse rate that was "significantly High elevated in the 145 beats per minute." He stated that when they arrived on the scene patient #10 was hooked up to her home oxygen concentration at 2 liters via nasal cannula. He also stated the patient was able to stand with the assistance of both EMS staff. The EMS staff further stated that after the patient was loaded in the ambulance, a more in-depth head to toe assessment was performed. He palpated the patient abdomen and patient #10 expressed some tenderness in the abdomen but did not flinch on assessment. The EMS staff stated that the patient had complained of diarrhea stools for 3 days. The 4 lead cardiac monitor was placed and showed a sinus rhythm of 140. The Patient denied shortness of breath, "but the patient sounded a little full to him." The EMS staff stated that the patient had an oxygen saturation level of 91% (slightly low) in the home. The EMS staff stated that he increased the patient's oxygen flow from 2 liters per minute to 3 liters per minute, and the oxygen level increased to 96%.



Patient #23:

An interview was conducted with patient #23 on 01/06/2016 at 1:11pm. She stated that on 12/16/15 she went to the emergency room (ER) due to severe back pain that was not controlled with her routine pain medications. Patient #23 stated that she had chronic back problems and chronic pain associated with those problems. She stated that after she arrived at the ER, she was taken to a room and a triage emergency medical technician (Staff E) came in to assess her. She stated that she told staff E that she was in severe pain and that the pain medications prescribed by her pain management physician were not working. She stated that at that point staff E told her that the ER was staffed only with an Advanced Registered Nurse Practitioner (ARNP) and that due to her being on pain management, he would not be able to give her any pain medication. She stated that she then left the ER. Patient #23 stated that she never saw a physician or the ARNP while she was in the ER. She stated that she was in excruciating pain that night and barely slept. The next day, she contacted her pain management physician who gave her permission to go back to the ER for treatment.

Emergency room record review for patient #23 showed that on 12/16/15 at 3:58pm patient #23 presented to the emergency department of Calhoun Liberty Hospital complaining of back pain. The record does not provide any information that would indicate that the patient was triaged by a triage nurse, or that the patient was assessed by a nurse, ARNP, or a physician. There was no evidence in the record that on 12/16/15 staff ever obtained a set of vital signs on the patient or that a pain assessment was completed. There was no evidence a Medical Screening Exam (MSE) was performed by a physician or nurse practitioner.

There was a note entered into the patient's record on 12/16/15 at 4:20pm which stated that patient #23 told triage staff that her pain medications were not helping and pain management would not change her medications. Patient #23 was advised that the facility would evaluate and treat her as necessary, but if she required medications, she would receive non-narcotic medications. The record then indicated that at 4:29pm, the patient left without being seen.

Interviews:

On 01/06/16 at 9:05am, an interview was conducted with the emergency medical technician (EMT) that was working triage in the ER on 12/16/15, when the patient presented to the ER. She stated that patient #23 had come into triage and stated that she had chronic back pain and wanted her medications refilled. She stated that she then went and talked to the nurse and ARNP on duty. She stated that she was told by the ARNP that he could not give the patient a prescription for narcotic medications. She stated that she returned to patient #23 in triage and told the patient that she could be seen for her pain and could receive non-narcotic pain medication but that the ARNP could not give her narcotic pain medication and the patient left. The EMT verified the patient did not see the ARNP.



On 1/6/16 at 8:44am the ARNP (staff D) working the emergency department on 12/16/15 was interviewed. He stated that patient #23 had come in complaining of chronic back pain and stated that her pain medication was not strong enough. Patient #23 stated that she was under pain management and that she had contacted her pain management physician, but he didn't want to do anything about it. Patient #23 was told that the ARNP would treat her but that he couldn't give her a prescription for narcotics and she became angry and left. He stated that due to Florida law, he is not able to give prescriptions for narcotics. He also stated that patients on pain management have to sign contracts and that giving the patient narcotic medication will break their contract and they can be dismissed from pain management for that. He stated that unless a patient on pain management has an acute issue or injury not related to their chronic condition for which they are being treated under pain management, it is normal procedure for them not to receive narcotic pain medications.



On 1/6/16 at 9:36am, an interview was conducted with the director of nursing who confirmed that an ARNP is not allowed to write a prescription for a schedule II narcotic, but can treat a patient onsite with those medications. She stated that the facility does have a physician that is on call 24 hours a day and can be called to give a prescription for these medications if needed. When asked if it was normal procedure for staff to tell patients that the ARNP can't provide them with prescriptions for narcotics, she stated that it was not. She stated that her expectation of staff and for all patients is that they be triaged, assigned an acuity rating, and placed in a room if available. She stated that if this conversation were to come up, she would expect that it take place between the patient and the ARNP after triage had been completed.

Policies and Procedures:

Policies that address EMTALA regulations were requested. The hospital provided a policy entitled, "E.D. Rules and Principles", last revised 11/11. The policy stated that "a. Any patient presenting to the ED will be triaged and medically screened." The hospital also provided an untitled policy dated 11/11 with the documented purpose, "to provide a means of compliance to COBRA/EMTALA rules and regulations for medical staff and hospital personnel." The policy stated, "It is the policy of the hospital Emergency Department that all patients presenting to the emergency department will receive a medical screening by the medical staff."

The policy on respiratory distress evaluations was requested for review. The hospital provided a policy entitled, "Shortness of Breath," effective 11/11. The purpose of the policy was, "To expedite the care of patients who present to the Emergency Department with the complaint of acute respiratory distress, shortness of breath." The procedure included but was not limited to:
1. Triage assessment to include lung sounds, oxygen saturation, quality of respirations, accessory muscle use and presence of edema and cough. 2. Notify doctor.
3. Obtain IV (intravenous) access and labs
4. Place patient on oxygen as ordered
5. Contact Respiratory for EKG (electrocardiogram) and /or ABG (arterial blood gases) as ordered
8. Chest X-Ray if condition warrants
15 Document interventions and patient's responses
Under the section "physician protocols" the document stated for pulmonary embolism:
- get CT of chest or VQ scan (ventilation/ perfusion lung scan)
-IV Heparin (a blood thinner)
-Assess for admission or transfer

The emergency department policy on triage was requested for review. The hospital provided a policy entitled, "Triage", dated 11/11. The triage stated that all persons presenting to the emergency department would be triaged by a licensed professional and appropriate treatment secured based on need and level of urgency. The triage procedure stated that an emergency room record would be completed on every patient that presents to the ER and an initial triage assessment would include, but is not limited to time/date of arrival, documentation of chief complaint, vital signs, and allergies.

The policy on pain assessment was requested for review. The hospital provided a policy entitled, "Pain Assessment ", dated 9/15. The policy stated that the patient has a right to appropriate assessment and management of pain and that failure to assess for pain increases the likelihood that pain will be underestimated, thereby leading to under treatment and increased suffering and loss of dignity for patients. Pain may be perceived as an emergency for the person experiencing it and a pain assessment is the cornerstone of all effective pain management. The policy further stated that pain is whatever the person says it is, whenever he says it is and that an assessment should be performed as part of the initial admission assessment procedure. According to procedure, the patient should be asked to describe the pain to discern location, quality, onset, duration, relieving factors, aggravating factors, and any associated factors.

The policy on change of condition assessment was requested for review. The hospital provided a policy entitled, "Notification of Physician of Change in Patient Condition", last revised 11/11. The policy stated, "The nurse assigned to the patient is responsible for informing the physician about a change in the patient's condition." The procedure included, "1. Inform the physician of his/her assessment of the patient's condition" and "4. In the event of acute deterioration, appropriate nursing interventions will be implemented. The ER physician may be contacted for immediate / emergency assistance. The responsible physician will be notified at the earliest opportunity regarding the patient's status and action taken."

The emergency department policy titled, "Calhoun Liberty Hospital Transfers" was requested for review. The policy stated in part, Calhoun Liberty Hospital must, within its capabilities, provide medical screening examinations and treatment, including hospitalization if necessary, to stabilize a patient ' s medical condition ...Procedure: The hospital will provide medical screening examinations to any persons presenting to the Emergency Department. The patient will be evaluated by a Physician or Qualified Medical Provider as qualified in the facility ' s By-laws and/or Rules and Regulations to determine if an emergency medical condition exists. "

The emergency department policy on assessment was requested for review. The hospital provided a policy entitled, "Assessment and Reassessment of the ED patient", dated 09/15. Under a section entitled, 'Nursing Documentation, the policy stated:
C. Nursing assessment of the problem will be completed by an RN, LPN, EMT or Paramedic and his/her interventions during triage noted.
D. Reassessment will be done as indicated per complaint/acuity and the treatments as prescribed.
E. Vital signs will be recorded as indicated for diagnosis and interventions. Vital signs include: blood pressure, heart rate, respiratory rate, temperature

The facility failed to ensure that their policies and procedures regarding appropriate medical screening examinations were followed as evidenced by failing to provide an appropriate medical screening examination that was within the capabilities of the hospital ' s ED to determine whet

Based on staff interview, patient interview, emergency room record review, and policy review, the hospital failed to explain risks and benefits of refusal and failed to take all reasonable steps to secure the individual's written informed refusal for 1 of 24 sampled patients (#23) who presented to the emergency department.

The findings include:

Record review for patient #23 showed that on 12/16/15 at 3:58pm patient #23 presented to the emergency department of Calhoun Liberty Hospital complaining of back pain. The record indicated that at 4:29pm, the patient left without being seen. There was no signed refusal of care document in her clinical record. There was no documentation that staff attempted to obtain an informed refusal for care. There was no documentation stating that risk and benefits were discussed. There was no documentation indicating that staff attempted to obtain an informed refusal. There was no refusal form in the patient's record. Additionally, there was no documentation indicating that the staff made effort on 12/16/2015 to obtain patient#23 ' s signature regarding informed refusal as stated in the facility policy and procedure.

An interview was conducted with patient #23 on 01/06/2016 at 1:11pm. She stated that on 12/16/15 she went to the emergency room (ER) due to severe back pain that was not controlled with her routine pain medications. Patient #23 stated that she had chronic back problems and chronic pain associated with those problems. She stated that after she arrived at the ER, she was taken to a room and a staff member came in to assess her. She stated that she told the staff member that she was in severe pain and that the pain medications prescribed by her pain management physician were not working. She stated that at that point the staff member told her that the ER was staffed only with an Advanced Registered Nurse Practitioner (ARNP) and that due to her being on pain management, he would not be able to give her any pain medication. She stated that she then left the ER.

On 1/6/16 at 1:54pm, an interview was conducted with the , Director of Nursing (DON) regarding the hospital process for refusal of care. The DON stated that if a patient leaves the hospital against medical advice (AMA) they have the physician and a witness fill out an AMA form and attempt to get the patient to sign the form if possible. She stated that if there was an issue around a patient leaving without being seen or if a patient were to elope, the staff were to record this in the nursing documentation section of the patient ' s medical record. The staff were no longer required to complete incident reports for patients that leave without being seen. She stated that this was something she had changed to help cut down on high volume of incident reports.

The emergency department policy on patients who leave without being seen was requested. The hospital provided a policy entitled, "AMA / Elopement", dated 10/2014. The policy stated that "attempts should be made to persuade the patient to remain in the hospital until the physician is contacted or arrives." Steps to be taken included, "1. The risk of leaving are to be explained fully to the patient. 2. A release from responsibility form is to be signed by the patient and witnessed by two individuals. Every effort must be made to obtain the patient's signature. "

Based on reviews of emergency department medical records, policy and procedures, Police reports, dashcam video recording and interviews with family member and facility staff members, the facility failed to provide an appropriate discharge for 1 of 24 sampled patients, #10, who was discharged with an unstabilized emergency medical condition while in the emergency department complained of shortness of breath on numerous occasions and collapsed in the hospital's parking lot and subsequently died in the hospital's emergency department.

The findings include:

Patient #10:

Medical record review

The review of the medical record revealed that on 12/21/2015 a discharge order was written at 4:18 a.m. for patient #10. The ED physician recommended that the patient have an outpatient work-up for the abdominal pain and GYN (gynecology) referral through her primary care physician. On 12/21/2015 4:20 a.m., Staff C, the ED paramedic documented that he "went to discuss discharge with patient." He documented that patient #10 refused vital signs and refused to leave. Several staff and family members tried to reason with her, but the patient refused to leave. Staff also documented that the patient refused to sign the discharge papers. The police department was called. Staff C also documented that patient #10 walked out of the facility on 12/21/2015 at 5:00 a.m. with a police officer in handcuffs. The ED physician documented on the Progress Notes, "at~ (approximately) 0520 I approached the patient which was on her knees on the ground next to the police vehicle back door with ED nursing staff present. I was informed briefly of the situation,pulse ox on patient at that time showed O2 sats 98% and HR (heart rate) ~70. On exam of patient pulses were present however she was not responding to verbal communication therefore I had her immediately brought back into ED for for evaluation. ..however patients pulse became weaker although still present and once in the ED Rm(room) 3 it was determined that she was pulseless (having no heart rate)and CPR (cardiopulmonary resuscitation- an emergency life saving procedure for reviving the heart and lung) via ACLS protocol was immediately initiated. The patient was intubated for respiratory support, IO (Intraosseaus cannulation-a needle placement directly into the marrow of the bone to provide a route for administering fluids and medications) access was obtained". The patient received ACLS medications and 2 (two) liters of NS (normal Saline). Further review revealed that aggressive and intense CPR measures were initiated for about close to an hour. The ED physician documented that "resuscitative measures were stopped and TOD (time of death) was called." Patient #10's time of death was called by the ED physician at 6:20 am on 12/21/2015.

Police Officer Report:

The police report dated 12/21/2015 at 4:46 a.m., regarding patient #10 was reviewed. The police report revealed that Patient #10 was placed under arrest for disorderly conduct and trespassing by the county Police Officer.

Dashcam Video recording review

Review of the dash cam video dated 12/21/2015 revealed that the Police officer came to the ED and asked a staff member what was going on. A staff member was heard informing the PO that Pt#10 did not want to leave and they had done everything they could. Patients Room in the ED and leaving the ED: The PO was heard asking Patient #10 how she was doing? Patient #10 replied "No Hell they didn't. The PO asked the patient her name twice .... The patient informed the PO "At this moment you need to leave my room .... I ain't telling you nothing" A male voice was heard in the background saying "You have been discharged." The patient stated, "No. No, No, No." The PO informed Patient #10 she could either walk out of the hospital or that he was going to take her out. The patient was heard telling the PO "I am really feeling sick here ..." Patient #10 was then heard moaning and groaning and then started to say OH my GOD over and over again. The PO was heard talking over the phone with someone and he (PO) was informed that they could not find any trespassing warrants against Patient #10. The PO asked patient#10 if she was "ready to go." The PO told Patient #10 that she could walk out of the hospital on her own will ... and that if she didn't feel that she was treated properly she could go to another facility." Patient was heard saying, "Oh yes I can." Patient #10 was heard saying "I can't hardly breathe ... this man done take this thing off of me." Patient #10 was heard yelling and screaming "leave me alone " ...I can't even breath---Wait- Wait Help me (family member name) ... I can't breathe x2" (at this point patient #10 sounded like she was Short of Breath) .... Family member was heard saying "Come on (Pt#10's name) let's go." The patient was heard saying, "No Please Don't let me die in here ... (Family member name) I am dying ...Stop don't hurt me ... I can't breathe (numerous times)." The PO was heard telling patient #10 to put her hands behind her back .... (The patient sounded like she was short of Breath) and the patient stated in part, "Please leave me alone ... They are going to kill me" (Sounded like the patient was still experiencing Shortness of breath). A Female voice in the background was heard saying "you gotta cooperate." The PO was heard asking Patient #10 to put her hands behind her back. Patient #10 was heard saying "Please sir leave me alone-Don't do me like this ... ...leave me alone ... (Family member name) They are going to kill me." (The Patient still sounded like she was Short of Breath). A female voice could be heard "They begged you to leave and you won't do it." At this point it could be heard that handcuffs were being placed on Patient #10. The patient was heard saying "No take that off please." The patient was heard saying "I can't go now." A female voice in the background was heard saying that Patient #10 was okay and that she hadn't been hooked up for a while and that she was breathing "just fine." Patient #10 was heard saying, "I can't go no more." (Patient#10 sounded like she was still experiencing Shortness of Breath). Patient #10 repeatedly asked the ED staff "Help Me! Please, ya'll help me ... I can't breathe!" Parking Lot: The PO was heard asking patient #10 please don't fall down. Patient #10 was not heard saying anything. From this point on attempts were made to place the patient in the police car but to no avail. The ED staff was checking the patients O2 saturation and heart rate: the following values could be heard: 1. 98% oxygen saturation and 70 heart rate; 2. 98% and 70; 3.) 97% and 67; 4.) heart rate 60 and 98% 02 saturation; and 5.).Heart rate 70 and 98% 02 saturation and that the patient had a carotid pulse. ... Sounded like the ED physician is in the parking lot and was evaluating the patient) The ED physician stated that he wanted the patient to be placed on a stretcher and taken into the ED. The ED physician was heard saying "I don't know what is happening now. This is totally different now than when I was discharging her. What happened?" A voice was heard in the background answering the ED physician "She wouldn't go." The family member was heard saying, "How you going to discharge somebody and she was still hurting."

Interviews

An interview was conducted with the Paramedic assigned to patient #10 on 12/29/2015 at 8:35 am. The paramedic stated that he would have gotten a complete set of Vital signs prior to discharge, but that patient #10 refused vital signs to be taken. He stated that the patient was not on oxygen at the time of discharge, and was not sure what time the oxygen had been removed. He stated that the patient had been off the oxygen for a long period of time prior to leaving the hospital. He also stated that Law Enforcement was called because the patient had been discharged, because she refused to leave the facility, refused to accept discharge summary, and was verbally abusive to staff members and acting in an aggressive manner. He continued to state that the PO and family members tried to talk the patient into leaving the hospital. It was not the intention to have Patient #10 arrested. He stated that the patient left the ER at 5:00 am, and that a staff member remained with the patient after she went down. He stated the patient's breathing, heart rate and oxygen saturation were appropriate. The paramedic stated that it was perceived as further resistance of arrest as had been displaying since vital signs were within normal parameters.

A telephone interview was conducted on 12/29/2015 from 11:08 pm (CST-Central Standard Time) thru 11:32 pm (CST) on 12/29/2015 with a family member of Patient #10. This family member was a witness to the event. She stated that Patient #10 requested to see the Administrator and was informed the administrator would not be in until 8 am. She stated that Patient #10 did not want to be discharged as was still having abdominal pain in her lower stomach. She stated that after discharge, the nurse kept asking her to sign it (discharge papers) about 3 times refused. She stated that Patient #10 was hurting too bad to leave. She also stated that Patient #10 stated that she would leave if she had her oxygen. The family member stated that the PO did give Patient #10 an option of walking away or be handcuffed, but she wanted to be admitted because her stomach was hurting.
On 01/14/2016 at 4:30 p.m., a telephone interview was conducted with the ED physician on duty when Patient #10 presented to the ED on 12/20/2015. He stated that patient #10 was admitted to the ED with no respiratory distress, and that the patient was able to ambulate about the room and shout and holler with no respiratory decompensation. There was no concern, "thinking she was going home." The ED physician stated that he was never informed she was being arrested. He continued to state that patient #10's Disposition was stable abdominal pain discharging home to normal state of outpatient. He stated that he was summoned to check patient #10 in the parking lot and she was assessed immediately when contacted. He stated that the patient was unconscious and not responding to verbal stimuli. He further stated that he detected palpable radial pulse, and auscultated apical pulses and breath sounds, but he wanted to get the patient back into the hospital to adequately evaluate her.

Policy and Procedure

The facility's policy and Procedure titled "Calhoun-Liberty Hospital Transfers" Effective date: 05/98, Revised date: 11/11. The policy and procedure stated in part, "POLICY: Calhoun Liberty Hospital must within its capabilities, provide ... treatment if necessary to stabilize a patient's medical condition ....PROCEDURE: ...In the event a medical emergency exists the facility will provide within its capabilities, treatments required to stabilize the medical condition."

There was no documentation in the medical record to indicate that an order was written for patient #10 to be discharged to jail on 12/21/2015. The facility failed to ensure that patient #10 was appropriately discharged as evidenced by failing to provide stabilizing treatment as required that was within the capability of the hospital's ED for patient #10 on 12/21/2015 in the event of a medical emergency for Patient #10 when she complained repeatedly of"difficulty breathing " , requesting"Help " from the ED staff and indicating that felt like she was going to die; while being led out of the hospital detained by the PO and accompanied by ED staff member. There was no documentation in the medical record as to the patient's stated complaints to the ED staff as she was being led out of the ED that oxygen was administered, or that she was assisted to a stretcher or chair to be assessed. There was no documentation that the ED physician was notified of patient#10's stated complaints, and a change in her condition prior to leaving the ED after she was discharged. The patient collapsed in the hospital's parking lot and died in the hospital's ED on 12/21/2015.