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Based on interviews, medical record reviews, ambulance reports, Grievance Form review, and review of the facility's Medical Staff , Rules, Policies and Procedures, it was determined the facility failed to ensure an individual with an emergency medical condition (EMC), received stabilizing treatment as required that was within the capabilities of the facility's Emergency Department (ED) to stabilize his/her medical condition for one (1) of twenty (20) patients medical records reviewed. Patient #1, who presented to the facility's Emergency Department on 01/18/2023 at 4:30 PM, was not provided further evaluation and treatment as required to stabilize other significant findings that were identified during her visit in the hospital's ED.

Refer to finding in Tag 2407.

Based on interviews, medical record reviews, ambulance reports, Grievance Form review, and review of the facility's Medical Staff , Rules, Policies and Procedures, it was determined the facility failed to ensure an individual with an emergency medical condition (EMC), received stabilizing treatment as required that was within the capabilities of the facility's Emergency Department (ED) to stabilize his/her medical condition for one (1) of twenty (20) patients medical records reviewed. Patient #1, who presented to the facility's Emergency Department on 01/18/2023 at 4:30 PM, was not provided further evaluation and treatment as required to stabilize other significant findings that were identified during her visit in the hospital's ED.

The findings include:

The facility's policy titled, "Medical Staff, Rules, Policies and Procedures-Part A Clinical, Part B Organization" was reviewed. The section titled ED, Rules and regulations revealed in part, "7. All patients presenting to the EMERGENCY DEPARTMENT seeking treatment shall be provided a medical screening examination by one of the ED practitioners to determine whether an EMERGENCY MEDICAL CONDITION exists. If an Emergency Medical Condition exists stabilizing treatment shall be provided, or the patient will be transferred, if a physician certifies in writing in writing that medical benefits of the transfer outweigh the risks, or the patient requests a transfer."


Review of the facility's policy tilted, "Reporting Clinical Laboratory Values", dated 12/06/2021, revealed all critical laboratory values were documented in the Laboratory Information System (LIS). The comments included the critical result/value, name of the person who received the critical value, date, time, and initials of the caller. Per the policy, critical laboratory values given over the phone required that the recipient of the results read-back the critical value to the caller for confirmation. The policy stated critical adult glucose values were less than fifty (50) milligrams per deciliter (mg/dl) and greater than four hundred (400) mg/dl.


Review of Patient #1's ambulance run sheet revealed the physical assessment vital signs for 01/18/2023 at 4:20 PM was a blood pressure of 98/54, pulse rate of 92, pulse oximeter (SPO2) 98%, and blood sugar of 324. The patient was awake alert and oriented x 4. Further review revealed in part, "Pt. (Patient) adv (advises) EMS (Emergency Medical Services) that she has been on the floor since yesterday (01/17/2023). Her pain 10/10 on the pain scale (pain scale-A pain score of 0 means no pain, and a Pain Scale of 10-means worse pain ever had) was a 10 on 01/18/2023 at 5:01 PM. She is having vaginal pain and that her vagina is raw along with the inside of her legs. Pt is presenting with hypotension (Low Blood Pressure)." The section of the report titled "Clinical Impression" stated the patient's chief complaint was "Vaginal Pain" and final acuity was listed as "Emergent." On 01/18/2023 at 4:30 PM, Patient #1's blood pressure was 122/80, pulse rate of 80, SPO2 98%, and blood sugar 324. Patient #1 was transferred from the ambulance to the hospital's ED at 4: 45 PM.

Review of Patient #1's ED medical record revealed the patient arrived at the facility's ED and was seen in Triage, on 01/18/2023 at 4:51 PM, 5:01 PM, and 6:05 PM, where the triage sepsis screen was documented as "no". The patient had a chief complaint of increasing confusion, with a fall at home. The patient stated he/she had head trauma without obvious loss of consciousness. Patient #1's family member stated he/she had been increasingly confused over the last two (2) to three (3) days. Patient #1 reported lower abdominal pain and right hip pain. Review of the vital signs upon admission on 01/18/2023 at 4:59 PM revealed a blood pressure of 100/89, pulse rate of 91, respirations 18, temperature 97.6 degrees Fahrenheit (F), and SpO2 96% on room air. Further review of the vital signs on 01/18/2023 at 5:20 PM revealed a blood pressure of 199/113, pulse rate of 77, and SpO2 96%. Further review of the vital signs on 01/18/2023 at 8:20 PM revealed a blood pressure of 161/108, pulse rate of 84, and SpO2 96%. Review of the final vital signs on 01/19/2023 at 1:20 AM, before the patient was discharged, revealed a sitting blood pressure of 139/77, resting pulse rate of 88, and SpO2 97% on room air. Review of the physical exam revealed the musculoskeletal system had tenderness with palpation of the right greater trochanter; the neurological system revealed Patient #1's mental status was alert and oriented to person, place, and time; and his/her mental status was at baseline.

Review of the medical record flowsheets, dated 01/18/2023 at 5:01 PM and 01/18/2023 at 6:05 PM, revealed, under infection documented or suspected, the word "none". Review of the physician's orders revealed Social Services was to contact home health to arrange their services upon discharge.

Continued review of Patient's #1 ED medical record revealed he/she received the following medications: two (2) Catapres (an antihypertensive to lower blood pressure) 0.1 milligram (mg); Benadryl injection (an antihistamine used to treat an allergic reaction) 25 mg; Neurontin capsule (an anticonvulsant used to treat seizures and nerve pain) 300 mg; insulin Humulin R injection (short-acting hypoglycemic used to treat high blood sugar) ten (10) units; insulin regular (short-acting hypoglycemic) three (3) units; Macrobid (an antibiotic used to treat a urinary tract infection) 100 mg; Protonix (used to treat gastroesophageal reflux disease) 40 mg; and two (2) Potassium Chloride 40 milliequivalents (mEq) added to each liter of intravenous fluids (IVF).

Continued review of Patient #1's ED medical record revealed one (1) intravenous (IV) access was placed with IVF of Normal Saline started. Diagnostic testing included an electrocardiogram (ECG, a test used to check the heart's rhythm and electrical activity); computed tomography (CT) of the head; and x-rays of the abdomen, pelvis, chest, with two (2) views of the femur. Blood work included a basic metabolic panel (BMP), a complete blood count (CBC), and a comprehensive metabolic panel (CMP).

Continued review of Patient #1's ED medical record revealed test results of the ECG were sinus rhythm with premature atrial complexes (are extra heart beats that starts in the upper chambers of the heart. My.clevelandclinic.org), incomplete left bundle branch block (An incomplete or partial block means the electrical signals are partly disrupted. https://www.verywellhealth.com) and when compared with the ECG of 09/02/2022, significant changes had occurred. An X-ray of one (1) view of the chest showed an increased size of the cardio-mediastinal silhouette since 10/05/2021, with a recommendation to correlate with a contrast-enhanced chest CT, at this time, to evaluate for vascular abnormality, mass, or pericardial effusion; CT of the head showed no acute intracranial hemorrhage or mass effect and left occipital chronic infarct; CT of the pelvis showed small bilateral nonobstructive nephrolithiasis and mild colonic diverticulosis; and two (2) views of the right femur revealed the study was significantly limited by the patient's morbid obesity, the proximal femur/femoral head was not well seen, and the femoral head was grossly located, but this study was not adequate to exclude a fracture, and there was severe degenerative change of the right knee. Documentation in the ED note the section titled "Medical Decision Making" revealed the patient's EKG was "Unremarkable." Further to review of the medical revealed there was significant changes in the patient's cardiac status. There was no documentation in the medical record to indicate that further evaluation was provided for the significant change in the patient's cardiac status.

Continued review of the medical record of the lab results for the CBC showed the white blood count (WBC) was high at 17.11 per cubic millimeter (normal upper level was 11.00); the CMP results were glucose was critically high at 746 milligrams per deciliter (normal non-fasting level was 70 to 130); blood urea nitrogen (BUN) was high at 36 milligrams per deciliter (normal upper level was 20); creatinine was high at 1.70 milligrams per deciliter (normal upper level was 1.04); Potassium was low at 3.2 millimoles/Liter (normal lower level was 3.5); alanine transaminase (ALT) was high at 571 units/Liter (normal upper level was 56): aspartate aminotransferase (AST) was high at 135 units/Liter (normal upper level was 32); total bilirubin was high at 1.6 milligrams per deciliter (normal upper level was 1.2); lactic acid, plasma, dated 01/18/2023 at 5:09 PM, was critically high at 4.7 millimoles per Liter (Normal mmol/L, reference range of 0.5-2.0 mmol/L); and a STAT order for lactic acid reflex, dated 01/18/2023 at 6:34 PM, revealed a critically high value of 3.5 mmol/L (reference range of 0.5-2.0 mmol/L). (High lactic acid levels severe medical illness with low blood pressure and too little oxygen is reaching the body's tissue). Review of the medical record revealed that the ED physician was notified of the critically high lactic acid, lasma, and the stat order for lactic acid reflux on 01/18/2023 at 6:34 PM, and no orders received.

Review of the glucose levels and insulin administration times per chronology were as follows:

Review of a BMP dated 01/18/2023 at 4:56 PM revealed a glucose of >599 milligrams per deciliter (mg/dl), as critically high.

Review of the ED record revealed insulin regular (Humulin R, Novolin R) Injection 10 units was given on 01/18/2023 at 5:05 PM IV per peripheral IV.

Review of CMP dated 01/18/2023 at 6:05 PM revealed a glucose of >746 mg/dl, as critically high (as above).

Review of a finger stick blood sugar check dated 01/18/2023 at 7:15 PM revealed a glucose of 597 mg/dl as critically high.

Review of a finger stick blood sugar check dated 01/18/2023 at 8:22 PM revealed a glucose of 567 mg/dl as critically high.

Review of BMP dated 01/18/2023 at 8:32 PM revealed a glucose of 572 mg/dl, as critically high (as above).

Review of the ED record revealed insulin regular (Humulin R, Novolin R) Injection 3 units was given on 01/18/2023 at 8:43 PM subcutaneously in the left upper abdomen.

Review of a finger stick blood sugar check dated 01/19/2023 at 12:36 AM revealed a glucose of 466 (mg/dl) as critically high.

Review of a BMP dated 01/19/2023 at 1:19 AM revealed a glucose of 345 mg/dl as high.

The ED notes dated 01/18/2023 at 11:16 PM, was reviewed. ED nurse documentation stated in part, "Upon charging the patient's bed, patient had severe red and raw areas in groin and perineal area. The area was warm, red, and excoriated. Area was covered in cat hair, old tissue paper and had a foul odor and stated her house should be condemned. Patient states SO (significant other) can't help her at home. I provided zinc to all excoriated areas."

Further review of the ED record Provider Note, dated 01/19/2023 at 12:42 AM, revealed, under medical decision making, the CBC noted leukocytosis, and the CMP noted hyperglycemia; the urine sample had not been obtained. Per the note, it stated the patient did have dysuria (pain and/or burning upon urination). The note stated the patient was started on Macrobid, and the final diagnoses were Urinary Tract Infection (UTI), Hyperglycemia, and Hypokalemia. Patient #1 was given prescriptions for Macrobid one (1) capsule by mouth two (2) times a day and Potassium Chloride 20 mEq one (1) tablet by mouth daily.


The Grievance form dated 01/27/2023 at 4:00 PM, submitted to the hospital by Patient #1's daughter was reviewed. The Grievance form stated in part, "My Mom (patient #1) was seen in our ED (Baptist Health Corbin) last Wednesday (01/18/2023), was discharged home from the ED and passed away at home in her sleep 14 hours following discharge. Daughter states she requested wanting to look at Nursing Home Placement for her mother but that she was aware of need for 3 days in -patient stay for Mom to qualify for Nursing Home Placement. She states there were no beds available, so she asked about her mom being transferred, and she states the provider told her, all her numbers were looking better and did not feel like she would be accepted for transfer to another facility. States she was discharged home with consult for Social Worker to follow-up. She feels like we need to review this as she doesn't think we provided patient with a safe discharge plan."

Review of the Patient's ED medical record revealed there was no documented evidence Social Services contacted the daughter or the patient for Home Health Services.

During an interview with the ED Medical Director, a Doctor of Osteopathic Medicine (DO), on 02/02/2023 at 8:48 AM, he stated Patient #1's care was handed over to him from another physician due to shift change. He stated the goal for the patient was to decrease blood sugars and improve clinical status after a fall at home where x-ray results showed no fractures. He stated Patient #1 was able to answer questions and did not seem to have any mental status changes. He stated Patient #1 had a history of a possible stroke in the past as seen from the results of the CT scan of the head. He stated Patient #1 had clinically stabilized, and x-rays showed no fractures, with no issues identified. He stated he gave an order to Social Services for an outpatient referral for home health services. He stated the patient had improved medically, clinically, and was ready for discharge to home.

During an interview with the ED Physician, on 02/02/2023 at 10:27 AM, he stated he did not remember Patient #1, but at shift change, he would have handed the patient off to another ED Physician. He stated if the patient had not complained about chest pains and with the results of the ECG, Patient #1 would not have met the criteria and triggers for the cardiac protocol or to take emergent action.

During an interview with Social Service Worker on 02/02/2023 at 2:18 PM, she stated they are available after hours 24/7. The on-call scheduler receives the referral from the provider and contacts the on call Social Service Worker. They will call immediately if the patient cannot go home safely and do not have anyone with them. The work cue lists the referral made to Social Services. They receive the call over the weekend and if not urgent, will check the work report on Monday for the referrals. According to the Social Service Worker, the referral order from the provider does not cancel upon discharge. Social Service staff are the only ones who can pull up the information and discontinue the order. Continued interview revealed that Patient #1 resides in Whitley County, a tri-county area and due to the Patient's insurance would not cover Home Health. Patient #1 was responsible for her own medical decisions, and the daughter was not listed on the FACE sheet (document that gives the patient's information at a quick glance www.caring.com) as a contact. According to the Social Service Worker, Social Services would have called the patient or the spouse.

During an interview with Patient #1's daughter, on 02/02/2023 at 10:38 AM, she stated her chief complaint was Patient #1 was falling a lot at home and seemed disoriented. She stated she felt the patient was acting differently, and Patient #1 had a history of a heart attack. She stated she traveled to the ED from out of town. She stated it was reported to her that Patient #1 had only been on the floor for about thirty (30) minutes before Emergency Medical Services (EMS) was called. She stated the ED checked the patient's blood sugars often, and they were high, and the patient had hypotension (low blood pressure). She stated blood sugars were elevated; however, they had decreased to 340. She stated she requested a three (3) day stay so she could place the patient in a nursing home. She stated she was told the patient had improved and beds at the hospital were full. The daughter stated she made a request for home health due to the patient's spouse having had recent surgery on his/her legs. Further interview revealed, no one contacted her concerning any Home Health Services. She stated she and Patient #1 were provided discharge papers with follow up with Patient #1's primary medical doctor in two (2) to three (3) days. The daughter stated she requested an ambulance to take the patient home because he/she could not walk. She stated the ambulance did take the patient home and assisted him/her to the couch. The daughter stated she left to return home and called frequently to check with the patient's spouse on how the patient was feeling. The daughter further stated about fourteen (14) hours later she contacted the spouse to check on the patient, and the spouse called back. She stated the spouse said the patient was cold to the touch. The daughter stated the coroner was called to the house, the patient was pronounced dead, and the cause of death was Diabetes and Heart Disease. She stated she filed a formal grievance with the hospital on 01/31/2023.


On 01/18/2023 Patient #1 required full stabilizing treatment for significant changes in her in cardiac status, critical laboratory values and severe skin impairments that were identified prior to discharge, despite the patient's daughter request to transfer the patient to another hospital because the patient required in-patient hospitalization in order to meet her identified critical needs.