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Based on document review and interview, it was determined the Hospital failed to ensure compliance with 42 CFR 489.24. Findings include:

The Hospital failed to stabilize an emergency medical condition and appropriately transfer a patient. See deficiency at A 2407.

Based on document review and interview, it was determined for 1 of 3 patients (Pt. #1) with complaints of chest pain, the Hospital failed to ensure stabilization of an emergency medical condition. Findings include:

1. The clinical record for Pt. #1 was reviewed on 07/30/13 at approximately 10AM. Pt #1, a 48 year old female, arrived at the Hospital's emergency department (ED) by ambulance on 07/23/13 at approximately 7:47 PM with a complaint of shortness of breath. The ambulance sheet dated 07/23/13 at 7:05 PM included, " ... was having pain in ...chest when breathing." The ED triage assessment at 7:45 PM included vital signs as temperature 98.6 pulse 89, respirations 18 and B/P 101/63. Pt. #1 was triaged as level 3 (patient requiring two or more resources [i.e., tests] with vital signs not in the danger zone. Pt. #1 was taken directly into the ED with a pain score of "5" (out of 10).

The medical screening exam completed by MD#1 dated 07/23/13 at 8:47 PM included,
"present with complaints of a cough for 3 days with generalized weakness, shortness of breath, fever and nausea. Pt. also reports a fall today with no loss of consciousness, but has some right shoulder pain ...lungs clear, alert, no acute distress."

While in the ED, the physician ordered the following tests:

a) cardiac marker test levels (Troponin, CK-MB), b) prothrombin time; c) blood cultures; d) complete blood count; e) antibiotics; f) one dose of morphine; g) Aspirin; h) portable chest x-ray; i) computerized tomography angiography(CTA) of the chest with contrast; and an electrocardiogram (ECG).

The following tests had abnormal results.

a)Pt.#1 had two elevated Troponin 1 levels on 7/23/13: 0.05 at 7:50 PM and 0.07 at 11:13PM. The Hospital laboratory reference range is less than 0.05 ng/ml. According to laboratory documentation, mild elevations may indicate non-infarction cardiac injury or early myocardial infarction;

b) Prothrombin time 15 (Hospital reference range is 9.4-11.8);

c) Two chest x-rays revealing excess fluid around the lungs and fluid inside the sac of the heart;

d) An ECG (dated 07/23/13 at 8:57PM) reviewed and initialed by (MD#1) documented ischemia (restriction of blood supply to tissue). The same ECG was interpreted by a cardiologist (MD#5) as abnormal when compared with Pt. #1's ECG of 07/16/13.

The ED physician's (MD#1) progress note (date 07/23/13 at 8:57PM) interpretation of the ECG as normal sinus rhythm unchanged from 2 weeks prior. MD#1 called Pt. #1's treating physician (MD#2) from previous hospitalizations, on 7/24/13 at approximately 2:04AM. "Reviewed diagnostic results and plan for admission. He (MD#2) informs me there is no point to admit her as her problems are chronic, related to primary pulmonary hypertension which has been thoroughly evaluated during her prior admission and that she has been repeatedly informed Condell lacks facilities to manage her disease and that she has been referred to seek care at a tertiary care center. Patient is aware of why she is not being admitted. Patient is resting comfortably. Patient is comfortable with discharge and follows up with Tertiary Care Center. Pt. understands that her pulmonary HTN has thoroughly been evaluated by Condell and must be treated at a tertiary care center. Pt. understands that this condition is a chronic condition. Pt. understands to return to ED if new symptoms develop or if pt. has any other concerns." Pt. #1 was discharged on 07/24/13 at approximately 2:57AM. MD #1 documented, "Condition stable, medically cleared and discharged home. " Pt. #1 subsequently presented to Cook County Hospital approximately 2 hours later on 07/24/13 where she sustained a cardiac arrest in the triage area and expired.

2. On 07/30/13 at approximately 11:15 AM, MD#1 was interviewed in the presence of MD#3 (Vice President of Medical Management), E#2 (Vice president of Nursing) and E#3 (Director of Quality). MD#1 was asked if Pt. #1 was stable. MD #1 stated, "It looks like she was not stable but based on her past history of pulmonary hypertension, the Patient was stable." MD #1 stated he called the physician (MD#2) who took care of her previously and discussed all the findings including the ECG. MD#2 did not want Pt. #1 admitted but instead discharged with instructions to follow up at a tertiary care hospital that treats pulmonary hypertension.

On 7/30/13 at approximately 1:55 PM, Triage Nurse (E#1) was interviewed. E#1 stated he remembered the Pt had chest tightness and went straight to the back for evaluation.

On 07/31/13 at approximately 9:50 AM, MD#2 was interviewed in the presence of the Vice President of Medical Management (MD#3), the Vice-President of Nursing (E#2) and Quality Director (E#3). MD #2 stated Pt.#2 was admitted on 06/23/13 for a cough, chest pain and shortness of breath and diagnosed with pulmonary hypertension. On 07/15/13 Pt. #1 presented to the ER for swelling of her legs and back pain and was admitted. MD#2 stated Pt. #1 was evaluated by a cardiologist during the 07/15/13 admission who diagnosed pulmonary hypertension. MD#2 stated that he spoke to MD#1 who thought Pt. #1 was stable with no new ECG findings. MD #2 stated that an elevated Troponin level has no clinical meaning in this case.

On 07/31/13 at approximately 9:50 AM, the Vice President of Medical Management (MD#3) stated Pt. #1's entire clinical picture should be evaluated and the elevated Troponin levels were not indicative a cardiac abnormality because the cardiac enzymes were normal.

On 8/01/13 at approximately 9:30AM, MD #4, (Board Certified emergency department physician) was asked to review Pt. #1's clinical record and give his professional opinion on the care Pt. #1 received. MD #4 stated that he could not speak to MD #1's thought process. MD #4 stated after reading the record, MD #1 wanted Pt. #1 admitted to the Hospital but the primary care physician relayed information that Pt. #1 had a cardiac work up 5 days earlier.

3. The above findings were verified with Administrative staff during an interview on 07/30/13 at approximately 2:00 PM.