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Based on medical record review and staff interview the hospital failed to provide an appropriate ongoing medical screening examination and stabilizing treatment within the capability of the Emergency Department (ED) for Patient #5, one of 20 records reviewed. This had the potential to affect all patients served.

Findings included:

Refer to A2406 and A2407.

Based on medical record review and staff interview the hospital failed to provide an appropriate and continuing medical screening examination within the capability of the Emergency Department (ED) for Patient #5, one of 20 records reviewed. This had the potential to affect all patients served.

Findings included:

Closed medical record review revealed Patient #5 was a 70-year-old male who presented to the Dedicated Emergency Department (DED) on 01/20/2022 at 1750 due to being "hit by a vehicle." Patient #5's vital signs at 1806 were: pulse (P) 102, respirations (R) 16, blood pressure (BP) 157/12 (sic), and SP02 93% room air and pain 6 out of 10 (0 no pain to 10 severe pain) in his neck. Review revealed orders were placed at 1756 for CT (cat scan) head, cervical spine, abdomen pelvis without contrast, chest x-ray, EKG (electrocardiogram), COVID test, CBC (complete blood count), CMP (comprehensive metabolic panel), PT (prothrombin time) with INR (international normalized ratio) and PTT (partial thromboplastin time).

Review of the DED triage note at 1808 revealed "Pt (patient) to ed (emergency department) via ems (emergency medical services) with cc (chief complaint) of neck pain. S/p (status post) pedestrian vs motor vehicle. Incident was reported to have occurred in the parking lot of a local food market. It was reported the pt. was struck and fell onto to the ground by a vehicle traveling at approximately 5 Miles Per Hour (MPH). He does not recall the events post event. The pt. arrived ... fully immobilized with BB (back board) and C-collar. He is CAOX4 (conscious and oriented) with a GCS (Glasgow Coma Scale) of 15 (15 normal). He is currently C/O (complaining of) neck pain only. There is no active bleeding present and dried blood is noted to his L (left) head. The pt. was (sic) taken to CT for a scan and will be evaluated for further abrasions and lacerations and injuries when he returns."

ED Course documentation on 01/20/2022 at 1900 documented contact was made with (Hospital A trauma center) transfer center trauma doctors would prefer to wait till all the scans are back we will still wait on the CT of the chest and CT of abdomen and pelvis. CT of the head suggested a small subdural (a collection of blood between the covering of the brain (dura) and the surface of the brain. Most often the result of a severe head injury. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death.). Patient hemodynamically stable and alert oriented GCS of 15. At 2029 case discussed with trauma physician at (Hospital A trauma center) who recommended just observation for 6 hours in the ER if he remains neurologically intact and stable he can be discharged home safely. Patient should be safe for discharge at around midnight.

At 2226 Patient found to be COVID-positive. He is being monitored and watched for total of 6 hours before being discharged home.

Review of a DED RN (registered nurse) note at 2232 revealed "Sat patient to fowler position. pt saturation dropped to 89%; informed dr. (Medical Doctor -MD #1)."

Review of a DED RN note at 2302 revealed "Upon entering into room, pt.'s O2 sats 86% RA (room air). Placed on 4L (liters) NC (nasal cannula), O2 sats improved to 94%. MD #1 and primary RN notified."

Review revealed at 2312 MD #1 selected Patient #5's disposition to home.

Review of MD #1's DED provider note at 2314 revealed "Patient presents with Pedestrian vs (sic) Motorized Vehicle Major. History of Present Illness (HPI) patient reportedly was stocking (sic) in a parking lot at Food Lion by slow-moving vehicle was (sic) knocked him to the floor and hit his head on the pavement posteriorly patient states he was knocked out for short while brought in via rescue and was in a c-collar backboard...After he received the CT head neck his C-spine was removed patient complaining of lower abdominal discomfort as well. Mostly complains of headache neck and shoulder discomfort he has had multiple surgeries for orthopedic DJD (degenerative joint disease) problems including neck bilateral shoulders back...CT of the head was unremarkable CT of his chest did not have any significant infiltrates, patient states she (sic) had COVID a few weeks ago and may still be testing positive now here for evaluation after closed head injury.

Clinical Impressions as of 01/202022 at 2314 Closed head injury, initial encounter SDH (subdural hematoma - a collection of blood between the covering of the brain (dura) and the surface of the brain. Most often the result of a severe head injury. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death.), COVID-19 virus infection, Hypoxemia, Trauma."

Review revealed on 01/21/2022 at 0011 MD #1 selected Patient #5's disposition to transfer to Hospital B.

Review of a DED RN note dated 01/21/2022 at 0112 revealed "UNABLE TO OBTAIN AMBULANCE TRANSPORT UNTIL AFTER 0800...DURING DAYLIGHT HOURS DUE TO WEATHER AND ROAD CONDITIONS."

Review of PA (physician assistant) #2's progress note on 01/21/2022 at 0214 revealed "0200 patient was signed out to me by MD #1, pending report for CTA (computed tomography angiography) chest with PCR testing positive for COVID. D-dimer elevated 16.91, CRP (C-reactive protein) elevated 5.9. ... Transfer pending to (Hospital B), ER to ER transfer, unable to obtain ambulance transport until after 0800 and 0700 for rural ambulance service, due to present weather, road conditions."

Review of RN #4's progress note on 01/21/2022 at 0818 revealed "Charge called (Hospital B) Transport, Unknown ETA (estimated time of arrival). (Hospital B) Mobile to transport patient."

Review revealed on 01/21/2022 at 0908 MD #3 selected Patient #5's disposition to home. Review revealed Patient #5 was administered 1 milligram IV (intravenous) of Dilaudid at 0922.

Review revealed Patient #5 was discharged home on 01/21/2022 at 1023.

Review revealed Patient #5 presented to Hospital B DED on 01/22/2022 at 2007 with a chief complaint of headache. Review of the DED triage note at 2010 revealed "Was hit by car on 1/20 in parking lot, hit on right side. Dx with subdural bleed, concussion. Was discharged next morning. Wife states pt is more confused, can't walk without assistance, sleeping a lot (sic). Has pain and spasms in bilateral shoulders/arms. Right leg pain. Neck pain, jaw pain. Alert and oriented x3 in triage."

Review of a MD DED attestation note from Hospital B dated 01/22/2022 at 2201 revealed "70-year-old male, presenting as a level 3 trauma after recent pedestrian versus car, struck by a car 2 days prior, with positive LOC...Seen at outside hospital reportedly with subdural hematoma, did not get repeat imaging and discharged. Presenting today with worsening headache, neck pain, endorsing change in sensation to upper extremities and leg weakness. On arrival, primary survey intact, GCS 15. CT imaging demonstrated epidural (sic) hematoma, unclear how it may have changed from prior. Neurosurgery service consulted, awaiting recommendations endorsed to oncoming ED team."

Interview on 03/15/2022 at 1904 with PA #2 revealed MD #1 transferred Patient #5's care to him at shift change. Interview revealed Patient #5 was set to transfer to Hospital B and he was awaiting transport which was delayed due to weather conditions. PA #2 stated he went off shift at 0500 on 01/21/2022 and was not aware as to why Patient #5 was discharged.

Interview on 03/15/2022 at 1911 with MD #1 revealed he was Patient #5's initial DED MD on 01/20/2022. MD #1 explained she spoke with Hospital A's trauma services about Patient #5's subdural hematoma and the need for transfer. MD #1 stated trauma services stated the subdural hematoma did not warrant transfer and Patient #5 could follow-up with them outpatient. MD #1 stated trauma services recommended to keep Patient #5 in the DED and observe him for 6 hours and if he was still neurologically intact, it was appropriate to discharge him home.

Interview on 03/16/2022 at 1313 with RN #4 revealed she was the charge nurse the day Patient #5 discharged from the ED. RN #4 stated it was reported at shift change that Patient #5 was awaiting transportation to Hospital B because he required supplemental oxygen overnight. RN #4 stated MD #3 had her to wake Patient #5 up and assess his need for supplemental oxygen. RN #4 stated after Patient #5 woke and ate breakfast, his supplemental oxygen was removed, and he tolerated room air fine. RN #4 stated she called Patient #5's wife and reviewed his discharge instructions with her over the phone and then again in person when RN #4 assisted Patient #5 into their car. RN #4 stated Patient #5 was discharged wearing two hospital gowns, she assisted him directly in the car, and he did not wait outside in the cold for his wife to arrive. RN #4 stated there should have been a set of vital signs obtained and documented in the medical record prior to Patient #5's discharge.

Interview on 03/17/2022 at 1254 with MD #3 revealed he was the MD that discharged Patient #5 on 01/21/2022. MD #3 explained Patient #5 required supplemental oxygen overnight and transfer to Hospital B was arranged due to him being COVID positive and hypoxic. MD #3 stated during the morning hours of his shift, Patient #5's supplement oxygen was discontinued, and he tolerated it well. MD #3 stated since Patient #5's hypoxia improved, he didn't require supplemental oxygen, and he "clinically improved;" he was medically stable to discharge home and follow-up with Hospital A's trauma services for his subdural hematoma. MD #3 stated Hospital A had MRI services, but did not feel an MRI was warranted due to Patient #5's negative CT cervical scans and mechanism of injury. MD #3 stated Patient #5 was stable for discharge.

Patient #5 did not receive an appropriate continuing medical screening examination. Patient #5 presented to another hospital on 01/22/2022 with complaints of continued pain and confusion.

Based on medical record review and staff interview the hospital failed to provide stabilizing treatment within the capability of the Emergency Department (ED) for Patient #5, one of 20 records reviewed. This had the potential to affect all patients served.

Findings included:

Closed medical record review revealed Patient #5 was a 70-year-old male who presented to the Dedicated Emergency Department (DED) on 01/20/2022 at 1750 due to being "hit by a vehicle." Patient #5's vital signs at 1806 were: pulse (P) 102, respirations (R) 16, blood pressure (BP) 157/12 (sic), and SP02 93% room air and pain 6 out of 10 (0 no pain to 10 severe pain) in his neck. Review revealed orders were placed at 1756 for CT (cat scan) head, cervical spine, abdomen pelvis without contrast, chest x-ray, EKG (electrocardiogram), COVID test, CBC (complete blood count), CMP (comprehensive metabolic panel), PT (prothrombin time) with INR (international normalized ratio) and PTT (partial thromboplastin time).

Review of the DED triage note at 1808 revealed "Pt (patient) to ed (emergency department) via ems (emergency medical services) with cc (chief complaint) of neck pain. S/p (status post) Pedestrian vs motor vehicle. Incident was reported to have occurred in the parking lot of a local food market. It was reported the pt. was struck and fell onto to the ground by a vehicle traveling at approximately 5 MPH (miles per hour). He does not recall the events post event. The pt. arrived ... fully immobilized with BB (back board) and C-collar. He is CAOX4 (conscious and oriented) with a GCS (Glasgow Coma Scale) of 15 (15 normal). He is currently C/O (complaining of) neck pain only. There is no active bleeding present and dried blood is noted to his L (left) head. The pt. was (sic) taken to CT for a scan and will be evaluated for further abrasions and lacerations and injuries when he returns."

ED Course documentation dated 01/20/2022 at 1900 - contact was made with (Hospital A trauma center) transfer center trauma doctors would prefer to wait till all the scans are back, we will still wait on the CT of the chest and CT of abdomen and pelvis. CT of the head suggested a small subdural (a collection of blood between the covering of the brain (dura) and the surface of the brain. Most often the result of a severe head injury. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death.). Patient hemodynamically stable and alert oriented GCS of 15. At 2029 Case discussed with trauma physician at (Hospital A trauma center) who recommended just observation for 6 hours in the ER if he remains neurologically intact and stable he can be discharged home safely. Patient should be safe for discharge at around midnight.

On 1/20/2022 at 2226 Patient #5 was found to be COVID-positive. He is being monitored and watched for total of 6 hours before being discharged home.

Review of a DED RN note on 01/20/2022 at 2302 revealed "Upon entering into room, pt.'s O2 sats 86% RA (room air). Placed on 4L (liters) NC (nasal cannula), O2 sats improved to 94%. MD #1 and primary RN notified."

Medical record review revealed on 1/20/2022 at 2312 MD #1 selected Patient #5's disposition to home.

Review of MD #1's DED provider note dated 01/20/2022 at 2314 revealed "Patient presents with Pedestrian Vs (sic) Motorized Vehicle Major. History of Present Injury (HPI) patient reportedly was stocking (sic) in a parking lot at Food Lion by slow-moving vehicle was (sic) knocked him to the floor and hit his head on the pavement posteriorly patient states he was knocked out for short while brought in via rescue and was in a c-collar backboard...After he received the CT head neck his C-spine was removed patient complaining of lower abdominal discomfort as well. Mostly complains of headache neck and shoulder discomfort he has had multiple surgeries for orthopedic DJD (degenerative joint disease) problems including neck bilateral shoulders back...CT of the head was unremarkable. CT of Chest did not have any significant infiltrates patient states she (sic) had COVID a few weeks ago and may still be testing positive now here for evaluation after closed head injury.

Clinical Impressions as of 01/20/2022 at 2314 documented closed head injury, initial encounter SDH (subdural hematoma - a collection of blood between the covering of the brain (dura) and the surface of the brain. Most often the result of a severe head injury. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death.), COVID-19 virus infection, Hypoxemia, Trauma."

Review of a DED RN (registered nurse) note on 01/20/2022 at 2232 revealed "Sat patient to fowler position. pt saturation dropped to 89%; informed dr. (Medical Doctor -MD #1)."

Review revealed on 01/21/2022 at 0011 MD #1 selected Patient #5's disposition to transfer to Hospital B.

Review of a DED RN note dated 01/21/2022 at 0112 revealed "UNABLE TO OBTAIN AMBULANCE TRANSPORT UNTIL AFTER 0800...DURING DAYLIGHT HOURS DUE TO WEATHER AND ROAD CONDITIONS."

Review of PA (physician assistant) #2's progress note dated 01/21/2022 at 0214 revealed "0200 patient was signed out to me by MD #1, pending report for CTA (computed tomography angiography) chest with PCR testing positive for COVID. D-dimer elevated 16.91, CRP (C-reactive protein) elevated 5.9. ... Transfer pending to (Hospital B), ER to ER transfer, unable to obtain ambulance transport until after 0800 and 0700 for rural ambulance service, due to present weather, road conditions."

Review of RN #4's progress note dated 01/21/2022 at 0818 revealed "Charge called (Hospital B) Transport, Unknown ETA (estimated time of arrival). (Hospital B) Mobile to transport patient."

Review revealed on 01/21/2022 at 0908 MD #3 selected Patient #5's disposition to home. Review revealed Patient #5 was administered 1 milligram IV (intravenous) of Dilaudid at 0922.

Medical record review revealed Patient #5 was discharged home on 01/21/2022 at 1023.

Patient #5 presented to Hospital B DED on 01/22/2022 at 2007 with a chief complaint of headache. Review of the DED triage note at 2010 revealed "Was hit by car on 1/20 in parking lot, hit on right side. Dx with subdural bleed, concussion. Was discharged next morning. Wife states pt is more confused, can't walk without assistance, sleeping a lot (sic). Has pain and spasms in bilateral shoulders/arms. Right leg pain. Neck pain, jaw pain. Alert and oriented x3 in triage."

Review of a DED note from Hospital B on 01/22/2022 at 2022 revealed "Pt was a pedestrian struck by a car 2 days prior. Today wife noticed increasing confusion and saying things that "weren't quite right". Pt also notes an increase in neck pain today as well. Pt currently AAOx4, in c-collar."

Review of a MD DED attestation note from Hospital B dated 01/22/2022 at 2201 revealed "70-year-old male, presenting as a level 3 trauma after recent pedestrian versus car, struck by a car 2 days prior, with positive LOC (loss of consciousness)...Seen at outside hospital reportedly with subdural hematoma, did not get repeat imaging and discharged. Presenting today with worsening headache, neck pain, endorsing change in sensation to upper extremities and leg weakness. On arrival, primary survey intact, GCS 15. CT imaging demonstrated epidural (sic) hematoma, unclear how it may have changed from prior. Neurosurgery service consulted, awaiting recommendations endorsed to oncoming ED team."

Review of Hospital B DED note on 01/23/2022 at 05:20, MRI wet read returned notable for T1 fracture and concern for ligamentous injury (occurs after a trauma).

Interview on 03/15/2022 at 1904 with PA #2 revealed MD #1 transferred Patient #5's care to him at shift change. Interview revealed Patient #5 was set to transfer to Hospital B and he was awaiting transport which was delayed due to weather conditions. PA #2 stated he went off shift at 0500 on 01/21/2022 and was not aware as to why Patient #5 was discharged.

Interview on 03/15/2022 at 1911 with MD #1 revealed he was Patient #5's initial DED MD on 01/20/2022. MD #1 explained she spoke with Hospital A's trauma services about Patient #5's subdural hematoma and the need for transfer. MD #1 stated trauma services stated the subdural hematoma did not warrant transfer and Patient #5 could follow-up with them outpatient. MD #1 stated trauma services recommended to keep Patient #5 in the DED and observe him for 6 hours and if he was still neurologically intact, it was appropriate to discharge him home. MD #1 stated the plan was to discharge Patient #5 home following the trauma services recommendations, however Patient #5 had tested positive for COVID while in the DED and experienced periods of hypoxia overnight. MD #1 stated he called Hospital A's transfer center back to inquire about a medical bed due to his hypoxia and there were no beds available. MD #1 stated he called Hospital B and they accepted Patient #5 as a medical transfer due to his hypoxia. MD #1 stated Patient #5's room air oxygen saturations were in the upper 80s and improved with 2 to 4 liters of supplemental oxygen. MD #1 stated by the morning of 01/21/2022, Patient #5's hypoxemia improved, and he was able to come off supplemental oxygen. MD #1 stated since Patient #5's hypoxemia improved and he wasn't requiring supplemental 02, he was discharged home and to follow up with Hospital A's trauma services regarding the subdural hematoma.

Interview on 03/16/2022 at 1313 with RN #4 revealed she was the charge nurse the day Patient #5 discharged from the ED. RN #4 stated it was reported at shift change that Patient #5 was awaiting transportation to Hospital B because he required supplemental oxygen overnight. RN #4 stated MD #3 had her to wake Patient #5 up and assess his need for supplemental oxygen. RN #4 stated after Patient #5 woke and ate breakfast, his supplemental oxygen was removed, and he tolerated room air fine. RN #4 stated she called Patient #5's wife and reviewed his discharge instructions with her over the phone and then again in person when RN #4 assisted Patient #5 into their car. RN #4 stated Patient #5 was discharged wearing two hospital gowns, she assisted him directly in the car, and he did not wait outside in the cold for his wife to arrive. RN #4 stated there should have been a set of vital signs obtained and documented in the medical record prior to Patient #5's discharge.

Interview on 03/17/2022 at 1254 with MD #3 revealed he was the MD that discharged Patient #5 on 01/21/2022. MD #3 explained Patient #5 required supplemental oxygen overnight and transfer to Hospital B was arranged due to him being COVID positive and hypoxic. MD #3 stated during the morning hours of his shift, Patient #5's supplement oxygen was discontinued, and he tolerated it well. MD #3 stated since Patient #5's hypoxia improved, he didn't require supplemental oxygen, and he "clinically improved" he was medically stable to discharge home and follow-up with Hospital A's trauma services for his subdural hematoma. MD #3 stated Hospital A had MRI services, but did not feel an MRI was warranted due to Patient #5's negative CT cervical scans and mechanism of injury. MD #3 stated Patient #5 was stable for discharge.

Patient #5 was not managed for his Subdural hematoma prior to discharge.