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Based on medical record review by a Board Certified Physician in Emergency Medicine, medical staff failed to be accountable to the Governing Body for the quality of medical care provided to Patient #1.

Findings include:

Review of the triage nursing notes in the medical record of the first hospital visit at Mercy Hospital-Orchard Park Division dated 12/7/12 at 0545 revealed Patient #1 presented with complaint of lower abdominal pain for two days. It is documented that the patient received chemotherapy four days prior to this event and had not moved her bowels for three days. Vital signs taken at 0557 revealed: B/P 190/70, Pulse 108, Respirations 22, Pulse oxygenation 95%. Pain level was documented as 10 of 10 on a pain scale.

Review of the physician documentation in the medical record of this first hospital visit dated 12/7/12 at 0617 revealed the patient presented with severe diffuse abdominal pain without radiation. Physical exam demonstrated mild abdominal tenderness in all quadrants with decreased bowel sounds.

Review of the Lab results in the medical record dated 12/7/12 revealed an elevated white blood cell count of 12,400, an elevated amylase of 264, an elevated BUN of 61, and elevated potassium of 5.7 with physician review documentation.

Review of abdominal x-ray dated 12/7/12 at 0842 revealed a single air-filled loop of small bowel. Review of the non-contrast CT scan of the abdomen dated 12/7/12 at 1028 revealed a stable ventral hernia and prominent constipation.

Review of Physician Documentation Disposition Summary dated 12/7/12 at 1115 revealed the patient was discharged to home with prescription for Miralax and follow-up instructions with private physician in 1-2 days. Impression: "Abdominal Pain, Constipation."

Review of the triage nursing notes in the medical record of the second hospital visit to the Emergency Department at Mercy Hospital-Buffalo Division dated 12/8/12 at 0033 revealed Patient #1 presented to Emergency Department with complaint of vomiting. Vital signs at 0037 revealed B/P 130/80, Pulse 100, Respirations 20, and Pulse Oxygenation 100%. Pain level was documented as 10 of 10 on pain scale. Nursing triage assessment at 0037 revealed Patient #1 appears ill, uncomfortable, behavior is restless.

Review of Physician Documentation under HPI dated 12/8/12 at 0053 revealed the following:
"The patient presents with abdominal pain that is diffuse. Onset: The symptoms/episode began/occurred gradually, 3 days (s) ago, and became worse today, at 0600. The symptoms do not radiate. Associates signs and symptoms: Pertinent positives: nausea, vomiting, poor PO intake, Pertinent negatives: chest pain, shortness of breath, vomiting blood, bloody stools. Modifying factors: The symptoms are alleviated by nothing, despite Mag Citrate, Miralax, mineral oil, 2 enemas (had small BM after first enema, no effect after second). Severity of pain: At its worst the pain was moderate in the emergency department the pain is unchanged. The patient has not experienced similar symptoms in the past. The patient has been recently seen at the CHS Emergency Department, MACC, today, earlier today, for similar symptoms, was given fluids, discharged with constipation. The patient states that her last bowel movement was on Tuesday, and her pain began Wednesday. She states she has vomited up all of the medications she has taken orally today for the constipation. She states she normally has a BM everyday. She states she had her last round of chemo on Monday, and on Tuesday was given a Neulasta shot."

Review of Physician Documentation under physical exam dated 12/8/12 at 0053 revealed: Abdomen/GI: "Inspection: distension, that is moderate. Bowel sounds: absent, in all quadrants. Palpation: soft moderate abdominal tenderness, in all quadrants. Rectal exam: rectal tone. Stool: guaiac positive."

Disposition Summary in the medical record dated 12//8/12 at 0347 revealed the Patient #1 was discharged to home with diagnosis of abdominal pain, nausea and vomiting. Prescriptions for Motrin and Zofran were given with follow-up instructions with private MD in 1-2 days. The CT scan and laboratory results of the previous ED visit were reviewed.

Review of the triage nursing notes in the medical record of the third hospital visit to the Emergency Department at Mercy Hospital-Buffalo Division dated 12/8/12 at 1555 revealed Patient #1 presented with onset of trouble breathing and vomiting dark for approximately one hour. Vital signs dated 12/8/12 at 1557 revealed B/P 100/60, Pulse 88, Respirations 22, Pulse Oximetry 95% on 3 liters oxygen via nasal cannula.

Review of Physician Documentation under physical exam dated 12/8/12 at 1754 revealed: Abdomen/GI: "abdomen appears normal, distension. Bowel sounds: diminished. Palpatation: mild abdominal tenderness." Respiratory: "mild respiratory distress is noted. Respirations: labored breathing. Breath sounds: rales, are not appreciated."

Review of Laboratory results in medical record dated 12/8/12 revealed a low white blood cell count of 1,600, elevated potassium of 6.8, and low sodium of 129.

Review of the abdominal x-ray completed 12/8/12 at 1732 revealed findings suggestive of a small bowel obstruction.

Review of Physician Documentation under MDM dated 12/8/12 at 1940 revealed: "worse when returned from x-ray required intubation then went into aystole, family wanted to stop resuscitation."

Review of Cardio/Pulmonary Resuscitation Record dated 12/8/12 at 1834 revealed asystole, 1835 Epinephrine administered, 1836 asystole; family requested all efforts stop. Patient #1 expired 12/8/12 at 1836.

Review of board certified Emergency Medicine physician (IPRO) consultant analysis dated 5/4/14 regarding Admission: #1 12/7/12-12/7/12 revealed the following:
-The patient did not receive adequate monitoring, testing and treatment consistent with the clinical presentation. "The patient should have had a rectal exam performed for stool guaiac. In lieu of an elevated BUN, potassium of 5.7 should have either been repeated or treated."

-Considering the patient's medical history, presentation and lab results; the CT of abdomen should have been ordered with contrast. "In a patient with previous abdominal surgery who presents with abdominal pain and constipation, small bowel obstruction must be ruled out. This is most efficiently done with a CT scan of the abdomen with PO contrast."

-Consideration should have been made to admit the patient for a higher level of care if she continued to have pain.

-The standard of care was not met for this episode of care. "The hyperkalemia should have either been determined to be laboratory error or treated. Evaluation and management of this patient's medical problems was incomplete."

IPRO review dated 5/4/13 regarding Admission: #2 12/8/12-12/8/12 revealed the following:
-The patient did not receive adequate monitoring, testing and treatment consistent with the clinical presentation. The patient had guaiac positive stool on exam. "The patient should have either had a nasogastric tube placed to see if she had an upper GI bleed or admitted and treated empirically."

-Repeat lab work and CT of abdomen with contrast should have been ordered.
"Laboratory tests should have been repeated to evaluate the patient's hyperkalemia and to see if the elevated white blood cell count was trending up or down."

-The patient should have been admitted to the hospital during this Emergency Department encounter. "At this point, the patient had returned a second time with 10 of 10 pain with only slight improvement with enemas. An elderly patient with multiple medical problems presenting a second time with abdominal pain should have been admitted for observation and pain control. Again since the record documents that the laboratory tests and CT scan from the previous admission were reviewed, the hyperkalemia and elevated white blood cell count should have been investigated further and treated."