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Tag No.: C2406
Based on staff interview and review of medical records, it was determined the CAH failed to ensure an appropriate medical screening examination was conducted for 1 of 21 patients (#9) who presented to the ED and whose records were reviewed. This impeded the CAH's ability to identify patients with emergency medical conditions. Findings include:
Patient #9's medical record documented a 90 year old male who presented to the ED on 8/28/13 at 11:11 AM.
The "St. Luke's McCall Emergency Department Nursing Flow Sheet," dated 8/28/13 but not timed, stated Patient #9 arrived via automobile and required maximum assistance from 2 people to transfer to a wheelchair. The Flow Sheet stated Patient #9 was not able to move his right foot or bear weight due to pain in his back, knee, and hip. The Flow Sheet included a space to document pain from 0 to 10 but this was left blank. The Flow Sheet stated Patient #9 was discharged at 2:27 PM on 8/28/13.
The "EMERGENCY ROOM REPORT" by the physician, dated 8/28/13 at 3:31 PM, stated Patient #9 presented "...with known diffuse arthritis status post bilateral knee surgeries has had unrelenting knee pain the last 18-24 hours." The Report stated, prior to presentation, Patient #9 was able to ambulate with the use of 2 canes. Under the heading "Hospital Course," the Report stated "...3 mL of 0.5 % Marcaine [a local anesthetic] were used to isolate the joint space. After this was injected into the joint space free flow of a turbid straw colored fluid came from the joint. There was no blood, however. 1 mL of Depo-Medrol [a steroid]...in 2 mL 0.5% Marcaine was then injected into the joint space." The Report stated Patient #9's pain was significantly relieved in 30 minutes.
No documentation was present in the record that a sample of the joint fluid from Patient #9's knee was sent to the laboratory for analysis.
Patient #9 presented to the ED again on 8/29/13 at 11:00 PM. He was treated by the same physician who treated him on 8/28/13. The "HISTORY & PHYSICAL/OBSERVATION NOTE," dated 11/29/13 at 11:50 PM, stated Patient #9 "...had severe pain today, came to the emergency room...and requested hospitalization this evening for pain control...He initially was using a walker and canes at home, but then was unable to bear any weight on his right lower extremity. He required a three person assist to get out of an automobile into wheelchair this evening...He had exquisite tenderness with any movement whatsoever in his right knee identical to that he presented with yesterday prior to his corticosteroid and bupivicaine injection."
Patient #9 was transferred to a room for observation. He was treated conservatively and was discharged home on 8/31/13 at 11:28 AM. A physician "DISCHARGE SUMMARY," dated 8/31/13 at 9:33 AM, stated Patient #9's pain had improved and he was currently maintained on oral pain medication. The note stated Patient #9 would follow up at a Veteran's hospital on 9/04/13.
Again, no documentation was present in the record that a sample of joint fluid was drawn and sent to the laboratory for analysis.
The Diabetic Coordinator was interviewed on 11/20/13 beginning at 4:00 PM. She stated she was also responsible for utilization review at the hospital. She stated Patient #9 was not admitted as an inpatient to the CAH on 8/29/13 but remained on observation status during his stay until his discharge on 8/31/13.
Patient #9 presented to the ED again on 9/01/13 at 7:34 PM. The record stated frank pus was aspirated from his knee at that time and he was emergently transferred to a Veteran's hospital for treatment.
The physician who treated Patient #9 on 8/28/13 and 8/29/13 was interviewed on 11/20/13 beginning at 3:35 PM. He stated on 8/28/13 he aspirated a small amount of yellowish fluid from Patient #9's knee during the process of injecting the joint. He stated he did not submit the fluid to the laboratory for analysis. He stated he heard later that Patient #9 passed away at the Veteran's hospital.
Patient #9 was a 90 year old male who presented to the ED with acute non-traumatic knee pain. The physician described the joint fluid from the knee as "turbid" but no further evaluation was done on the aspirant. The hospital did not conduct an appropriate MSE and failed to rule out an emergency medical condition for Patient #9.
Tag No.: C2407
Based on staff interview and review of medical records and hospital policies, it was determined the CAH failed to ensure 1 of 21 patients, whose medical records were reviewed (#8), received stabilizing treatment for an emergency medical condition. This resulted in the inability of the hospital to ensure a patient's condition was not likely to deteriorate after discharge. The findings include:
1. Patient #8 's medical record documented a 53 year old female who presented to the ED on 8/22/13 at 8:00 PM. Patient #8's presenting complaint was insulin overdose. She stated she accidentally self-administered Lantus Insulin 45 units and Levemir Insulin 45 units at 7:00 PM.
A laboratory report, dated 8/22/13 at 8:45 PM, stated Patient #8's glucose level was critically high at 621. Normal was listed as 60-100.
The "Emergency Department Nursing Flow Sheet" documented, on 8/22/13 at 9:00 PM, "Pt states she is sweaty & nauseated-not feeling right." The note stated Patient #8 was medicated with Ativan. A Flow Sheet on 8/22/13 stated the physician was notified of the critically high glucose level. A Flow Sheet on 8/22/13 at 9:40 PM stated Patient #8 was transferred to an observation bed.
Patient #8's "HISTORY & PHYSICAL/OBSERVATION," dated 8/23/13 at 12:10 AM, stated her diagnoses included insulin dependent diabetes, severe anxiety, agoraphobia, depression, migraines, and chronic pain syndrome. The H&P stated Patient #8 had a glucometer at home to measure her blood sugar, but it was broken. The H&P stated, on 8/22/13 at 8:45 PM, her blood glucose level was elevated at 621. The H&P stated "Diagnostic Impression: Acute iatrogenic insulin overdose without significant systemic effect." The H&P stated Patient #8 was referred for observation. The H&P stated Patient #8 would be monitored with blood glucose checks every hour. The H&P stated the hospital contacted Poison Control who recommended the hourly checks. The H&P stated if Patient #8's blood sugars did not dip too low, she would be able to be discharged after 6 hours. The H&P stated "The patient passed through observation without difficulty. She did have some anxiety and so was given Ativan. She also complained of migraine headache and so was given Toradol and Ultram for her discomfort. She was nauseated today so she was given Zofran 8 mg with good relief of symptoms." The H&P continued "At this time the patient is discharged home. She is advised to carefully watch her insulin when she is administering it. Her daughter will be helping her. Otherwise, she is to follow up with [a physician assistant] for ongoing evaluation and treatment." The H&P did not address Patient #8's critically high blood glucose level.
"OBSERVATION/EXTENDED RECOVERY GUIDELINES & ORDERS," dated 8/22/13 at 9:15 PM, called for finger stick glucose [every 1 hour] until 0100 ...If [blood glucose is greater than or equal to] 120, pt may be discharged home. "
Only 2 follow up blood glucose levels were documented. The "DIABETIC RECORD" stated the glucose levels were 421 at 11:33 PM on 8/22/13 and 366 on 8/23/13 at 12:46 AM.
The "PHYSICAL ASSESSMENT & SHIFT SUMMARY" stated, Patient #8 was given Zofran 8 mg for nausea at 11:18 PM on 8/22/13. The last nursing progress note was documented on 8/22/13 at 11:48 PM. It said Patient #8 "states having a panic attack. Ativan given IV. Nausea med helping a little."
An order to discharge Patient #8 to home was documented at 1:40 AM on 8/23/13. The order was not signed.
A discharge note was not documented for Patient #8. The time she was discharged was not documented. Her condition at discharge was not documented.
A form titled "Discharge Instructions," printed on 8/23/13 at 12:53 AM, stated "Continue previous meds as directed." The Instructions also stated to follow up with her physician assistant as soon as possible. The medical record did not document what Patient #8's normal dose of Insulin was supposed to be. The "Discharge Instructions" did not state how Patient #8 should resume her Insulin or what dose to take. The "Discharge Instructions" did not state how Patient #8 was to check her blood glucose levels since she did not have a functional glucometer.
The Clinical Supervisor for the Emergency Department was interviewed on 11/21/13 beginning at 10:30 AM. She reviewed Patient #8's medical record, and confirmed the documentation. She confirmed the discharge orders were not signed by the physician. She confirmed the physician's order for BS q1 hr. until 0100. She confirmed the lack of documented blood sugar levels. She confirmed a progress note containing details of Patient #8's discharge had not been written. She confirmed Patient #8's lack of a functional glucometer. She confirmed the lack of discharge instructions. She confirmed Patient #8's condition on discharge was not documented.
Patient #8's physician was interviewed by telephone on 11/23/13 beginning at 2:00 PM. He confirmed the "HISTORY & PHYSICAL/OBSERVATION" form and the orders in Patient #8's record. He stated he had written the discharge order but confirmed it was not signed. He stated Patient #8 's blood glucose level was typically in poor control due to her non-compliance. When asked what he had done for the Patient #8 's critically high blood glucose level, he confirmed he had not treated her for that. He stated Patient #8 had not been in ketoacidosis, a potentially life threatening complication of diabetes. He stated she may or may not have taken the insulin dose she claimed. He confirmed he did not document if Patient #8 was stable or not. He stated he was not sure how to document patient stability within the medical record. When asked how Patient #8 was to check her blood glucose level after discharge since she was without a functional glucometer, he stated he did not know.
The critical access hospital did not ensure Patient #8 was stabilized prior to discharge.
2. The Policy "EMTALA," not dated, covered medical screening examinations, transfers, and on-call physicians. The policy stated the purpose of the MSE was to determine whether or not the patient had an emergency medical condition. The policy stated, if the patient had an emergency medical condition, stabilizing treatment would be provided. The policy did not direct staff how to document that patients were stable for discharge.
The Clinical Supervisor for the Emergency Department was interviewed on 11/21/13 beginning at 10:30 AM. She confirmed the EMTALA policy did not direct staff how to document patients had been stabilized.
The critical access hospital's policies did not direct staff on how to document patients were stable for discharge.