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Based on review of a 20 patient sample of emergency department medical records, interview with facility staff members and review of the policies and procedures, it was determined that the hospital failed to comply with the provider agreement as defined in 42 CFR 489.24(b), to comply with 42 CFR 489.24. Patient identifier:6.

Findings include:

1. The hospital failed to comply with 42 CFR 489.24(a) and 489.24(c) by providing an appropriate medical screening examination to 1 patient (6) of the sample.

2. The hospital failed to comply with 42 CFR 489.24(d)(1-3) because appropriate stabilizing treatment was not provided for 1 patient (6) of the sample.

Based on review of a patient sample of twenty emergency department (ED) medical records and interview with staff members, it was determined that the hospital failed to provide an appropriate medical screening examination for one patient (identifier 6), within the capability of the hospital's ED, including ancillary services routinely available to the ED, to determine if an emergency medical condition existed. Patient 6 was transferred from a local skilled nursing facility (SNF) to the ED due to the abnormal test result of an elevated INR (International Normalized Ratio). The INR is a laboratory test used to monitor the effectiveness of Coumadin (an anticoagulant). An elevated INR would be indicative of a high risk of bleeding. The hospital did not conduct any laboratory tests or other diagnostic tests to evaluate and determine if patient 6 had an emergency medical condition.

Findings include:

MEDICAL RECORD REVIEW

Review of the emergency department medical record for patient 6 revealed the following information:

Patient 6 was a ninety three year old female who presented to the ED via EMS ambulance on 1/18/11 at 11:26 AM. Patient 6's chief complaint was documented as a laceration and coumadin use (anti-coagulant). Patient 6 was transferred from a local SNF.

1. Review of the nurse's triage documentation revealed that patient 6's vital signs upon arrival to the ED were temperature 94.1 (considerably below the a normal), pulse of 100 (elevated heart rate) and respirations of 18. The patient's oxygen saturation level was 98% on 10 liters of oxygen by mask. The triage nurse documented what medications patient 6 was currently taking at the SNF. The list included Coumadin 5 mg to be given on Tuesday and Thursday and Coumadin 4 mg to be given on the remaining days of the week.

2. The ED nurse's documentation indicated that patient 6 had a "V" shaped laceration on the left hand, which had occurred the day before. The dressing was changed and a new dressing was applied. There was "minimal" bleeding from the wound. Patient 6 was placed on a cardiac monitor and a pulse oximeter (instrument which measures oxygen levels).

The ED nurse documented that a physician was paged at 1:20 PM. There was no indication which physician was paged or why. The nurse documented that she called the nursing facility regarding patient 6's need for Vitamin K (an antidote for over anti-coagulation from coumadin use). The nurse documented that "we don't have any Vit. K in the hospital. Pharmacy can't obtain it from any other pharmacy places. MD aware. (name of nursing facility) checking to see if they have some. (Name of ambulance) here to transfer pt. back..." There was no nursing documentation indicating that any further diagnostic tests were done in the ED.

3. Review of a form titled: "Emergency Physician Orders" revealed the following: There were no orders for laboratory tests or other diagnostic tests. The only order was written by a nurse for Vitamin K 10 mg. to be given by injection. The time the order was written was 12:32 PM. Along with the order the nurse wrote the following: "Our pharmacy doesn't have any vit. K in house. MD aware. I spoke with (name of nurse at the nursing facility) about vit. K need. She stated they have it there and will administer it when she returns back there". The physician co-signed the order. There were no physician orders for laboratory tests such as CBC, Chemistry Panel, or repeat INR (to compare with the results of the INR drawn at the SNF).

4. Review of a form titled Emergency Physician Record: Abscess / Puncture Wound / Laceration was reviewed. The form was dated 1/18/12, at 12:06 PM. The form was in a template formate with boxes for the physician to check concerning the results of his examination. The physician documented that patient 6's chief complaint was a laceration and elevated INR. The physician documented that the patient had thin skin and probably bumped into something at the nursing home. The physician documented that little other history was available other than a brief report from the on call physician. Patient 6 was unable to talk. "I have no information on this pt." Under the section for additional information the physician documented that patient 6 was DNR (Do Not Resuscitate) and was to receive "comfort measures only". The physician documented that patient 6's INR was reported to be greater than 11 (therapeutic range is 2.0 to 3.5). The physician also documented "wound is well dressed at NH (nursing home) and has achieved hemostasis (no longer bleeding). I do not feel that a take down is warranted." The nurse documented that the dressing was changed but it is unclear in the documentation whether the physician observed the actual laceration without the bandage.

The physician documented that his review of physical systems on patient 6 was negative except as otherwise indicated. Beneath this statement the form included a check list for each of the following systems: General, Eyes, Ear Nose and Throat, Respirations, Cardiovascular, Gastro-Intestinal, Genito-Urinary, Skeletal, Skin, Neuro/Psychological and Endocrine. There were no boxes checked indicating the physician actually considered each system.

The form included a section for the physical examination of patient 6. The physician documented that he reviewed the ED nurse's documentation of patient 6's vital signs. The physician documented that the vital signs were stable. The vital signs were listed as temperature 94.1 (marked low), pulse 100 (normal 60 - 80), and an oxygen saturation level of 98% on 10 L of Oxygen. The vital signs documented, did not include a blood pressure. The physician documented on the check list that all areas of his physical examination were within normal limits. The physician put a check mark by the statement "I have performed a medical screening evaluation" and check marked the statement "No emergency medical condition exists". The physician documented that his clinical impression and diagnosis were: left upper extremity skin abrasion and elevated INR. The special discharge instructions for the SNF nurse were listed as "Stop Coumadin" "Please give her Vitamin K 10 mg IM (injection into the muscle) upon return to you ( SNF)." "Watch for signs of infection".

The physician documented the following evaluation: "pt (patient) is somnolent (sleepy and difficult to arouse) she is not in distress. Based on the information I have - she is @ baseline".

5. The medical record included a copy of the discharge instructions which were sent with the patient to the SNF. Hand written on the form was a set of vital signs. The temperature was 97.4, the pulse was 92, the respirations were 20, the blood pressure was 162/110 (high blood pressure) and an oxygen saturation of 97% on 2 liters of oxygen. There was no documentation indicating who had taken the vital signs or if the physician had been informed.

6. The medical record included the ED physicians dictated addendum note dated 1/18/12. "For history and physical, please see the template. As near as I could we discussed with the nursing home and confirmed that the patient is at her baseline. I discussed this several times with (name of physician) the physician on call. We have contacted the nursing home several times and as near as we can tell she is at her baseline. After discussion with (name of on-call physician), he recommended we give the patient some vitamin K and then stop her coumadin and send her back to the nursing home; it seemed like an appropriate plan. Unfortunately, the hospital is out of vitamin K and that is not an option from Davis Hospital. Therefore, we are going to check and see if that is an option from the nursing home; however, I have few other options. Certainly with the level of resuscitative efforts, the patient does not wish to have done transfusions, etc., does not seem to be an option. For further information, please see the computerized template".

7. The medical record for patient 6 included a copy of her advance directives. The form titled "Physician Order For Life Sustaining Treatment". The information included the statement: "Do not attempt or continue any resuscitation (DNR)". The form indicated that the treatment options desired. The option listed on the form was documented as "Comfort Measures Only". This would include oral fluids and body hygiene, reasonable efforts to provide food and fluids orally, medication, oxygen and pain relief measures to decrease suffering. The patient could be transferred to hospital only if comfort measures were no longer effectively being managed in the patient's current setting. There was no indication that if the patient was transferred to a hospital's ED due to a medical condition an appropriate medical screening examination could not be completed. The advance directives were signed by patient 6's son and daughter.

REVIEW OF INFORMATION SUPPLIED BY THE NURSING FACILITY

1. The SNF's nurse sent a form to the hospital, when patient 6 was transferred which included information concerning patient 6's condition. The form included the treatments and medications being provided at the SNF. Patient 6's symptoms requiring the transfer to the hospital were listed as INR 11 and "Unable to control bleeding (L) hand skin tear". The SNF's nurse documented that the wound had been dressed with an ABD (thick absorbent dressing) and Coban wrap. The nurse described patient 6 as alert but confused. Patient 6's communication ability was noted to be "Can Speak".

The information supplied by the SNF nurse included the telephone number for patient 6's son who was listed as the emergency contact.

The form included the patient's primary care physician's orders for the cares being provided in the SNF. Patient 6 was receiving rehabilitation therapy aide services to maintain ambulation and transfer skills. Patient 6 was being weighed weekly and the physician ordered that if there was a decrease in weight it was to be reported to the director of nurses. The physician had ordered multiple medications for patient 6 to take. Review of the physician's orders revealed that patient 6 was receiving services to prevent a decline in condition, not to provide comfort measures only.

2. The form documented patient 6's medical information concerning patient 6's current problems necessitating transfer to the ED. The form included documentation of the nursing care which was provided to patient 6 prior to her transfer to the hospital.

On 1/18/12 at 6:30 AM the facility nurse documented that a dressing on a skin tear to patient 6's left hand was saturated with blood. The nurse documented that the dressing was changed to an ABD (thick absorbent pad) and Coban wrap. The facility nurse documented that patient 6 was on coumadin therapy so a stat PT/INR was ordered. The results of the INR were documented as 11. At 11:30 AM, the nurse documented that she notified patient 6's primary physician of patient 6's increased bleeding from the laceration and the elevated INR results. The facility nurse documented that patient 6 was transported to Davis Hospital at 11:30 AM. as ordered by the physician.

On 1/19/12, at 6:30 AM, the day after patient 6 returned to the SNF from the ED, the nurse documented that patient 6 had received vitamin K 10 mg. the evening before. At 9:30 AM. a stat PT/INR was drawn. Patient 6's routine medications were held due to her decreased level of consciousness. At 10:30 AM. the SNF nurse documented that she called patient 6's daughter regarding patient 6's condition. At 11:30 AM, the facility nurse documented that she received a call from the physician's office. The nurse explained patient 6's condition and voiced concerns regarding patient 6's status and that she may have internal bleeding. An order was given to do a quiac test on patient 6's stool. A quiac test would indicate if there was blood in the stool. The nursing facility nurse documented that the quiac test was positive. Patient 6's physician ordered that patient 6 be transported to the hospital for evaluation and treatment. The facility nurse documented that the patient's oxygen level was 79% (normal is above 90%) on room air prior to her transfer. This oxygen level reading was markedly low. At 12:00 noon the nurse documented that patient 6 was transported to Davis Hospital by ambulance. At 12:05 PM. the facility nurse called Davis Hospital to give report to the emergency department staff. The emergency room physician informed the facility nurse that if the concern was patient 6's decreased level of consciousness, the patient should go to another hospital, because the CT scanner was not working. The physician informed the nurse that she would talk with the paramedics about sending patient 6 to another area hospital. Patient 6 was transported to the other hospital.

MEDICAL RECORD FROM THE SECOND HOSPITAL'S EMERGENCY DEPARTMENT

Patient 6 arrived at the hospital on 1/19/12.

1. Review of the ED physician's dictated report revealed the following:

Patient 6's chief complaint was documented as "High INR, GI bleeding, altered mental status".

The physician documented that patient 6 was a 93 year old female transferred by ambulance from the SNF. The physician documented that patient 6 was taking coumadin due to chronic atrial fibrillation (irregular heart beat). The physician documented that patient 6 had sustained a superficial laceration on her left hand the day before and was seen at Davis Hospital ED where she was found to have an INR greater than 11. The physician documented that the bleeding had been controlled with the application of pressure to the wound. The ED physician documented that the patient had been given Vitamin K by the nursing home staff that morning. (This is incongruent with the SNF's documentation which indicated patient 6 received the Vitamin K the night before). The nursing home staff had reported that patient 6 was much less responsive that day. The nurse noted in the transfer information that even though patient 6 had dementia she was usually awake and responsive to staff. The patient was usually alert but she did not talk much. The physician documented that patient 6 was not able to verbally give any information. "All of the history was obtained from the care center staff, and from the physician at Davis, who reviewed the records there".

The ED physician documented in his physical examination that patient 6 had a functional ileostomy with evidence of blood in the stool (black in color).

The ED physician documented that patient 6 received treatment, diagnostic studies and medical decision making while in the ED. The treatment included an immediate 500 cc IV infusion of normal saline, then another 500 cc over 30 minutes to an hour, then 250 cc an hour. "We immediately began typing and crossing for packed cells (blood transfusion) as well as fresh frozen plasma (counteracts the anticoagulation effect of the coumadin), as I presume that her INR was still going to be quite high".

Review of patient 6's laboratory values revealed a 14.4 INR the normal range is 0.9 to 1.2. The therapeutic range with the use of coumadin therapy would be higher at 2.0 to 5.0. Patient 6's prothrombin time (PT) was 137.5. The normal range was 9.7 to 11.6. These values would indicate a high risk for abnormal bleeding

Review of patient 6's urinalysis results revealed 4+ blood in the urine. Normally there is no blood in the urine

The ED physician noted that patient 6's sodium level was 164. The normal range is 136 to 145. The chloride level was 125. The normal range is 97 to 107. The BUN which is an indicator of kidney function was 106. The normal is 7 to 18. The creatinine level was 1.98. The normal range is 0.60 to 1.30. The physician documented that the laboratory results could be an indicator of acute kidney failure due to volume depletion (dehydration). Patient 6's hematocrit was 50.4. The normal range is 35.1 to 45.7. This could be an indicator of hemoconcentration and dehydration. The ED physician documented that patient 6 had a CT scan done emergently due to her altered mental status because there was a concern about a bleed in the brain due to the elevated INR. The CT scan results indicated no evidence of an acute problem in the brain.

The ED physician documented in his case evaluation that patient 6 had coagulation problems due to being medicated with coumadin. Patient 6 had evidence of an upper gastric bleed with grossly black quiac positive stools. The Ed physician documented that patient 6 was markedly dehydrated causing her elevated sodium level and her "acute renal failure". The ED physician documented that the cause of patient 6's altered mental status was not entirely certain although it could have been due to her elevated laboratory values and volume depletion. Patient 6 was admitted to the hospital's intensive medical unit for treatment with fluids and fresh frozen plasma to reverse her blood coagulation problem.

The ED physician documented that patient 6 had an advanced directive which included a DNR (Do Not Resuscitate) order, however the directive documented permission for limited treatment including fluids. "Therefore, we felt that the above treatment was appropriate". The ED physician considered patient 6's advanced directives and still provided an appropriate medical screening examination and treatment.

The ED physician stated that he spoke with patient 6's son when he arrived at the ED. The physician discussed the severity of patient 6's illness and that efforts that would be made to hopefully correct the elevated INR and dehydration. The treatment could improve patient 6's mental status. There was no documentation that the son refused the prescribed treatment because it was too aggressive or out of sync with patient 6's advanced directives.

INTERVIEWS

On 3/8/12, a tour of the ED was conducted with the nurse manager and director of nurses. The manager was questioned about the availability of a CT scanner. She stated that the ED had a dedicated CT scanner and there was another CT scanner in the hospital's X-Ray department.

On 3/8/12, at 1:30 PM, an interview was conducted with the chief nursing officer (CNO). The CNO stated that there had been a time when both of the hospital's CT scanners were down at the same time. She stated that she thought one of the scanners had some sort of electrical problem and the other had a blown tube. She stated that the hospital used the CT scanner at a physician's office building, located through the hospital's parking lot. She stated that only one patient had been sent to the physician's office to receive a CT scan. She stated she was unaware that any patient had been diverted to another hospital because the CT scanners were down. She stated that she was unaware of an incident where an ambulance was diverted to another hospital after it had arrived on their hospital property.

On 3/8/12, at 2:30 PM, an interview was conducted with the hospital's risk manager and the CNO. The risk manager stated that she was unaware of any problem concerning patient 6's 1/18/12 visit to the ED. The risk manager and CNO were informed that patient 6 was transferred from a local SNF due to an elevated INR of 11. The risk manager asked who the physician was. The risk manager asked whether the SNF personnel had obtained the INR results with the SNF's monitor or from a laboratory. The risk manager questioned the need for a repeat INR in the ED. The risk manager questioned if the SNF nurse had informed the ED physician of patient 6's INR. The risk manager stated that since the patient's presenting problem was a laceration, the physician may have been concentrating on that and was not aware of the elevated INR. The risk manager was informed that the medical record included a transfer form from the SNF nurse documenting that patient 6 was being transferred to the ED due to uncontrolled bleeding from a laceration and an elevated INR.

Neither the risk manager or CNO was aware of any patient being diverted to another hospital's ED because the hospital's CT scanners were not functioning. Neither knew of a case where an ambulance was diverted to another hospital after it arrived on the hospital's property. Patient 6 was discussed including the fact that the SNF where patient 6 resided was near the hospital (across the street and about a block away). She stated that EMS personnel would often radio the hospital's ED while still at the SNF rather than in transit to The ED or on the hospital campus.

Based on review of a patient sample of 20 emergency department medical records and interview with hospital staff members, it was determined that the hospital failed to provide treatment for an unstable medical condition or provide for a transfer to another facility, for one patient (identifier 6). Patient 6 was transferred from a skilled nursing facility (SNF) to the hospital's emergency department (ED) with the chief complaint of laceration on her left hand and an elevated INR of 11. The hospital failed to provide an appropriate medical screening examination and treatment of an emergency medical condition. The next day the patient was transferred from the SNF to another local hospital's ED. The patient's INR had increased and the patient's level of consciousness had decreased. Patient 6's condition required admission to the hospital for three days.

MEDICAL RECORD REVIEW

1. Review of the medical record revealed that patient 6 was a 93 year old female who was transferred from a local SNF to the hospital's ED with the chief complaint of laceration on her left hand.

The ED nurse's documentation indicated that patient 6 had a "V" shaped laceration on the left hand which had occurred the day before. The ED nurse documented that the dressing was changed and a new dressing was applied and there was "minimal" bleeding from the wound. Patient 6 was placed on a cardiac monitor and had a pulse oximeter (measures oxygen levels) in place. The nurse documented that a physician (not the ED physician) was paged at 1:20 PM. The was no indication why the physician was paged. The nurse documented that she called the nursing facility regarding patient 6's need for Vitamin K (an antidote for over coagulation from coumadin use). The nurse documented that "we don't have any Vit. K in the hospital. Pharmacy can't obtain it from any other pharmacy places. MD aware. (name of SNF) checking to see if they have some. (Name of ambulance) here to transfer pt. back..." There was no documentation indicating that other nursing cares were provided.

2. Review of a form titled: "Emergency Physician Orders" was reviewed. There were no orders for laboratory tests or other diagnostic tests. The only order was written by a nurse for Vitamin K 10 mg. by injection. The time the order was written was 12:32 PM. Along with the order the nurse documented the following: "Our pharmacy doesn't have any vit. K in house. MD aware. I spoke with (name of nurse at the SNF) about vit. K need. She stated they have it there and will administer it when she returns back there". The time the note was written was 12:45 PM. The physician co-signed the order. The nurse documented that patient 6 was transferred back to the SNF for treatment with a vitamin K injection. There were no orders for additional treatment in the ED. Due to the lack of an adequate medical screening examination, the ED physician could not diagnose complications such as dehydration, an electrolyte imbalance or renal failure in order to provide treatment.

3. The ED medical record included the ED physician's dictated addendum dated 1/18/12. "For history and physical, please see the template. As near as I could we discussed with the nursing home and confirmed that the patient is at her baseline. I discussed this several times with (name of physician) the physician on call. We have contacted the nursing home several times and as near as we can tell she is at her baseline. After discussion with (name of on-call physician), he recommended we give the patient some vitamin K and then stop her coumadin and send her back to the nursing home; it seemed like an appropriate plan. Unfortunately, the hospital is out of vitamin K and that is not an option from Davis Hospital. Therefore, we are going to check and see if that is an option from the nursing home; however, I have few other options. Certainly with the level of resuscitative efforts, the patient does not wish to have done transfusions, etc., does not seem to be an option. For further information, please see the computerized template."

4. The medical record for patient 6 included a copy of her advance directives which the SNF nurse sent to the hospital along with other information. The form was titled "Physician Order For Life Sustaining Treatment". The information included the statement: "Do not attempt or continue any resuscitation (DNR)". The form documented the treatment options desired for patient 6 to be "Comfort Measures Only". These measures were listed as oral fluids, body hygiene, reasonable efforts to provide food and fluids orally, medication, oxygen and pain relief measures to decrease suffering. The form documented that the patient could be transferred to the hospital only if comfort measures could no longer be effectively managed in the patient's current setting. There was no indication that should the patient be transferred to the hospital for a medical condition, that a complete medical screening examination should not be done. There was no indication that patient 6 could not be treated for an illness or the side effects from a prescribed medication such as coumadin. The form indicated that the patient could be treated with antibiotics and a defined trial of IV fluids. The form was signed by patient 6's son and daughter. There was no evidence that the family was contacted by the ED physician to discuss the patient's condition and what treatment options the family might desire for treating patient 6's present condition.

REVIEW OF INFORMATION SUPPLIED BY THE NURSING FACILITY

1. The SNF nurse sent forms with information concerning patient 6's medical condition and the treatments being provided at the SNF. The reasons for transferring patient 6 were listed as INR 11 and "Unable to control bleeding (L) hand skin tear". The SNF nurse documented that the wound had been dressed with an ABD (thick absorbent dressing) and a coban wrap. The nurse described patient 6 as alert but confused. Patient 6's communication ability was noted to be "Can Speak".

The information supplied by the nursing facility nurse included the telephone number for patient 6's son who was listed as patient 6's emergency contact.

The form included the primary physician's orders for the care provided in the SNF. Patient 6 was receiving rehabilitation therapy aide services to maintain an ambulation and transfer program. The orders stated that patient 6 was to be weighed weekly. A decrease in weight was to be reported to the director of nurses. The form indicated that patient 6 was treated with multiple medications. The information provided by the nursing facility indicated that patient 6 was receiving services and treatments to reduce patient 6's risk of decline and not comfort measures only.

2. Information provided with the complaint included nursing notes from the SNF's medical record for patient 6. The review of the medical record included the following information:

On 1/18/12 at 6:30 AM the facility nurse documented that a dressing covering a skin tear on patient 6's left hand was saturated with blood. A dressing change was done with an ABD and Coban wrap. The SNF nurse documented that patient 6 was on coumadin therapy so a stat PT/INR lab test was ordered. The results of the INR were documented as 11. At 11:30 the nurse documented that she notified patient 6's primary physician concerning patient 6's increased wound bleeding and the elevated INR results. The facility nurse documented that patient 6 was transported to Davis Hospital at 11:30 AM. per the physician's order.

On 1/19/12 the day after patient 6's readmission to the SNF the nurse documented at 6:30 AM that patient 6 had received vitamin K 10 mg. IM (by injection) the evening before. At 9:30 AM. a stat PT/INR was done. The SNF nurse documented that patient 6's routine medications were held due to patient 6's decreased level of consciousness. At 10:30 AM. the SNF nurse documented that she called patient 6's daughter regarding patient 6's condition. At 11:30 AM, the facility nurse documented that she received a call from the physician's office. The nurse explained patient 6's condition and voiced concerns regarding the possibility that she may have internal bleeding. An order was given to the nurse to do a quiac test of patient 6's stool. A quiac test indicates the presence of blood in the stool. The nursing facility nurse documented that the quiac test was positive. The physician gave an order for patient 6 to be sent to the hospital for evaluation and treatment. The facility nurse documented that prior to transfer patient's oxygen level was 79% (normal is above 90%) on room air. This was marked low. At 12:00 noon the SNF nurse documented that patient 6 was transported to Davis Hospital by ambulance. At 12:05 PM. the facility nurse called Davis Hospital to give report to the emergency department staff. The emergency room physician stated that if the concern was patient 6's decreased level of consciousness she should go to another hospital because Davis Hospital's CT scanner was broken. The nursing facility nurse documented that the ED physician informed the nurse that she would talk with the paramedics about sending patient 6 to another area hospital.

MEDICAL RECORD FROM THE SECOND HOSPITAL'S EMERGENCY DEPARTMENT

Patient 6 arrived at the second hospital on 1/19/12.

1. Review of the ED physician's dictated report revealed the following:

Patient 6's chief complaint was documented as "High INR, GI bleeding, altered mental status".

The physician documented the following:

Patient 6 was a 93 year old female transferred by ambulance from the SNF. Patient 6 was taking coumadin due to chronic atrial fibrillation (irregular heart beat). Patient 6 sustained a superficial laceration on her left hand the day before and was seen at Davis Hospital ED. She was found to have an INR greater than 11. The bleeding had been controlled with the application of pressure to the wound. The ED physician documented that patient had been given Vitamin K by the nursing home staff that morning. (This was incongruent with the nursing home documentation which indicated that patient received Vitamin K the night before). The nursing home staff noted that patient 6 was much less responsive that day. The SNF nurse noted in the transfer information that even though patient 6 had dementia she was usually awake and responsive to staff but did not talk much. The physician documented that patient 6 was unable to provide information him any information because she was non-verbal. "All of the history was obtained from the care center staff, and also from the physician at Davis, who reviewed the records there".

The ED physician documented in his physical examination that patient 6 had a functional ileostomy with black stool in the ostomy bag.

The ED physician documented that patient 6 received treatment and diagnostic studies. The patient was given an immediate 500 cc IV infusion of normal saline, then another 500 cc over the course of 30 minutes to an hour, then 250 cc an hour. "We immediately began typing and crossing for packed cells (blood transfusion) as well as fresh frozen plasma (component in the plasma to counteract the anticoagulant of the coumadin), as I presume that her INR was still going to be quite high".

Review of patient 6's laboratory results revealed an INR level of 14.4. The normal range is 0.9 to 1.2. The therapeutic range with coumadin therapy is 2.0 to 3.5. Patient 6's prothrombin time was 137.5. The normal range is 9.7 to 11.6 seconds.

Review of patient 6's urinalysis results revealed 4+ blood in the urine. Normally there is no blood in the urine

The ED physician noted that patient 6's sodium level as 164. The normal range is 136 to 145. Patient 6's chloride level was 125. The normal range is 97 to 107. These results could indicated an electrolyte imbalance. The BUN which is an indicator of kidney function was 106. The normal range is 7 to 18. The creatinine was of 1.98. The normal range is 0.60 to 1.30. The physician documented that the abnormal laboratory results could be an indicator of acute kidney failure due to volume depletion (dehydration). Patient 6's hematocrit was 50.4 (normal range of 35.1 to 45.7). These results could be indicative of hemoconcentration and dehydration. The patient had a CT scan done emergently due to her altered mental status due to a concern about bleeding in the brain due to the elevated INR. The CT scan results indicated no evidence of an acute problem with the brain. The physician documented that patient 6 had an advanced directive which included a DNR (Do Not Resuscitate) order. However the directive documented permission for limited treatment including fluids. "Therefore, we felt that the above treatment was appropriate".

The ED physician documented in his case evaluation that the patient had coagulation problems due to being medicated with coumadin. Patient 6 had evidence of an upper gastric bleed with grossly black, quiac positive, stools. Patient 6 was markedly dehydrated causing her elevated sodium level and her "acute renal failure". The ED physician documented that the cause of patient 6's altered mental status was not entirely certain although it could have been due to her elevated laboratory values and volume depletion. Patient 6 was admitted to the hospital's intensive medical unit for treatment with fluids and fresh frozen plasma to reverse the anti-coagulation effects of coumadin

The ED physician discussed patient 6's serious condition with her son when he arrived at the ED. The physician discussed what efforts could be made to correct the elevated INR and dehydration in the hopes of improving patient 6's mental status. There was no documentation that the son refused the prescribed treatment because it was too aggressive or out of sync with the intent of patient 6's advanced directives.

INTERVIEWS

1. On 3/8/12, at 1:30, an interview was conducted with the nurse manager of the ED. She stated that she was unaware of the situations concerning patient 6 which occurred on 1/18/12 and 1/19/12. She stated that she knew about both CT scanners being out of order at the same time but could not remember the date. She stated that there was a CT scanner was available at a physician's office building near the hospital. She stated she had no knowledge of a patient being diverted to another hospital, for a medical screening examination and treatment due to the CT scanners being down.

2. On 3/8/12 at 2:00 PM, an interview was conducted with the Pharmacy Director, concerning the unavailability of Vitamin K to treat patient 6 on 1/18/12. The director stated that there was a time in January or February when the hospital was out of adult injectable Vitamin K. He stated that the Vitamin K was on back order and there was a industrial shortage of Vitamin K. He stated that there was still oral vitamin K and pediatric Vitamin K available. He explained the difficulty with the scarcity of some drugs and being unable to acquire the drugs from the drug suppliers. He stated that on occasion they were able to obtain the drugs which were out of stock from their sister hospitals.

He stated that he was aware of a situation where a patient needed injectable Vitamin K and there was none in the hospital. He stated that several options were discussed. He stated that he thought that the involved patient was unable to take oral Vitamin K due to having difficulty with swallowing. He stated that they had considered using a larger volume of pediatric Vitamin K in order to administer the ordered dosage. He stated that the SNF nurse was contacted and Vitamin K was available there and the nurse agreed that the Vitamin K would be administered upon patient 6's return.

3. ON 3/8/12, an interview was conducted with the hospital's CNO and risk manager. The lack of an appropriate medical screening examination and treatment for patient 6 was discussed. The risk manager was unaware of the situation. The risk manager was made aware of the fact that patient 6 was a transfer from a SNF with the chief complaint of bleeding from a laceration on her hand and an elevated INR of 11. The risk manager questioned the need for the hospital to repeat an INR because one had been done that day at the SNF. The risk manager stated that the physician had treated the patient for a laceration and the bleeding had been controlled. The CNO and risk manager were aware of the shortage of Vitamin K which had occurred and indicated the hospital currently had injectable Vitamin K in stock.

Neither the CNO or the risk manager were aware of any patient being diverted from the ED due to the hospital's two CT scanners being out of order. The risk manager stated that she was usually aware of any possible EMTALA violation. The risk manager and the CNO were not aware that due to a lack of Vitamin K a patient had been discharged from the ED with the understanding that Vitamin K would be administered at the SNF.