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Based on interviews and documentation review, it was determined the Hospital failed to provide a MSE to Patient #1 when her friends indicated she was not feeling well and had vomited and asked if she could be admitted; minutes following her discharge from the ED.

Findings included:

Medical record documentation indicated Patient #1; a female college student, presented to the ED/ED Registered Nurse (RN) #1 ambulatory, at 11:36 PM on a January 2010 evening, with complaint of 7-8/10 right-sided abdominal pain (7 to 8 on a scale of 0-10 with 0 representing no pain and 10 representing the worse pain ever experienced by the Patient) radiating to her right flank, of 1 hour's duration. She was evaluated by ED Physician #1 and treated with intravenous (IV) fluid, Dilaudid (a narcotic pain medication) and Zofran (a medication that prevents or relieves nausea/vomiting).

ED Physician #1 was interviewed in person at 7:30 AM on 5/25/10. She reported re-evaluating Patient #1 about a half-hour following the Dilaudid/Zofran administration and finding her feeling better. ED Physician #1 also reported discussing possible causes of abdominal pain (such as mittelschmerz [abdominal pain occurring at the time of ovulation] and ovarian cyst) and pelvic examination with Patient #1 and said the Patient indicated she had had a recent pelvic examination and at that time; everything was OK.

Documentation indicated ED Physician #1 ordered IV Toradol (a nonsteroidal anti-inflammatory pain medication) for Patient #1 at 1:00 AM and it was immediately administered.

Documentation indicated Patient #1's symptoms were improved at 1:30 AM and at 2:30 AM; her IV infusion was discontinued and she was discharged home with a prescription for Motrin (a nonsteroidal anti-inflammatory pain medication) and Discharge Instructions. The Discharge Instructions included instructions to take the Motrin 3 times/day and to follow-up with a Primary Care Physician in 2 days.

Patient #1 was interviewed by telephone at 10:40 AM on 5/27/10. She said just prior to her ED discharge, she told the ED Physician she was not feeling any better, and the Physician told her she was being discharged and could/should follow up with the College Doctor.

Patient #1 said she left the ED with 6 female roommates/friends and as she approached the (Ambulatory Entrance) ED Exit; she felt like she was going to throw-up, and quickly grabbed a trash can from the Waiting Area. She said a woman sitting at the (Reception) Desk gave her a pink basin and as she was vomiting into the basin; her friends told the Woman she was not OK to be going home, and asked if something could be done. Patient #1 said the Woman then went into the ED to ask the Doctor if she could stay (at the Hospital).

The person assigned to the ED Ambulatory Entrance Reception Desk at the time of Patient #1's departure from the ED (ED Greeter #1) was interviewed by telephone at 2:10 PM on 5/24/10. ED Greeter #1 said Patient #1's name seemed familiar, but she could not recall her. ED Greeter #1 also said: the ED sees many, many college students; college students often arrive to the ED accompanied by friends; if a person wants to be evaluated in the ED (or someone representing the person indicates the person wants/needs to be evaluated), the person is evaluated even if he/she was just discharged from the ED and; if a patient has a post-ED discharge question or issue, she gets a nurse (to help the patient).

ED RN #1 was interviewed by telephone at 3:50 PM on 5/25/10. She said she triaged (screened to determine treatment priority) Patient #1 upon her arrival to the ED and later, when she was summoned to the ED Ambulatory Entrance Waiting Area by the ED Greeter because some girls were upset because their friend was not feeling well; she recognized the girls as Patient #1's friends. ED RN #1 said there were 3 or 4 friends and as she approached them: they all began talking at once and she could hardly understand what they were saying, but she was able to glean that Patient #1 was not feeling well and had vomited, and they wanted to know if Patient #1 could be admitted. ED RN #1 reported putting her hands up and saying "No", "Stop", "Wait" in effort to get Patient #1's friends to stop talking all at once. ED RN #1 also reported: wondering where Patient #1 was; wanting to find Patient #1 and assess her; ED RN #2 entering the Waiting Area 3-4 steps behind her and walking right past her and over to a young woman sitting in a chair with a pink basin; observing ED RN #2 talking with the young woman with the pink basin and; telling Patient #1's friends she would talk with the ED Physician.

ED RN #1 did not instruct Patient #1' s friends to bring and/or assist in bringing Patient #1 into the ED for a re-examination/second MSE.

ED RN #2 was interviewed in person at 11:20 AM on 5/25/10. ED RN #2 and ED Greeter #1 did not recall ED RN #1 intervening with a group of college-aged females that were simultaneously talking in the ED Ambulatory Entrance Waiting Area.

ED RN #1 said she spoke with ED Physician #1 regarding Patient #1's friend's reports and questions and ED Physician #1 told her to assess Patient #1 and bring her back into the ED if needed.

ED RN #1 said she returned to the ED Ambulatory Entrance Waiting Area to find Patient #1's friends standing together; off to the side, and ED RN #2 still talking with the young woman sitting in the chair with the pink basin. ED RN #1 reported assuming ED RN #2 was attending Patient #1, and approaching to communicate ED Physician #1's instructions. She said as she approached, ED RN #2 said she was "all set", and believing ED RN #2 was assessing Patient #1; she left Waiting Area.

Patient #1 said a short while after the Woman from the Reception Desk went into the ED to ask the Doctor if she could stay, another woman came out of the ED and told her friends: No, she could not stay; she should go home and follow-up with the College Doctor in 2 days. Patient #1 did not know who this Woman was, but said she was not the ED Physician or the Nurse who cared for her in the ED, and she did not know if the Woman was a nurse.

ED RN #2 did not recall attending to a patient in the ED Ambulatory Entrance Waiting Area following the patient's discharge from the ED or ED RN #1 approaching her while she was talking with/attending to a patient. ED RN #2 said that if she was aware of a patient feeling sicker/worse following discharge from the ED, she would have told the patient to come back into the ED. She also said the ED Physicians are always very willing to re-evaluate patients and routinely do so.

Patient #1 reported emptying and washing out her pink basin and leaving the ED with her friends. She also reported: feeling a tiny bit better and seeing the College Doctor the following day and; being referred back to the ED and undergoing gynecological surgery the day after that.

Documentation indicated the Hospital received a Complaint regarding Patient #1's ED care and a Complaint Investigation was conducted. The Investigation determined communication issues, a possible EMTALA violation related to the provision of a MSE to Patient #1 and documentation issues related to reassessments. A Corrective Action Plan including EMTALA education was developed and implemented and a meeting including Hospital staff, Patient #1 and Patient #1's Mother to discuss the Complaint, Complaint Investigation and Corrective Action Plan was scheduled.

Documentation indicated EMTALA Education Sessions were conducted on 5/7, 5/12, 5/14 and 5/18/10, and more Sessions were scheduled. Documentation also indicated EMTALA Education was incorporated into Hospital Orientation and Nursing Staff Annual Competencies.

The Hospital is in the process of educating staff (including physicians) regarding communication within a Building the Culture of Safety and High Reliability Initiative. The education includes education regarding hand-off communication utilizing SBAR (a model for communication of clinical/patient information [S = situation, B = background, A = assessment, R = recommendation]). The Hospital is also in the process of implementing hourly Patient Rounds that include pain assessments/pain assessment documentation.