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Based on medical record reviews, physician and staff interviews the hospital failed to ensure stabilizing treatment was provided for a patient who presented to the hospital's DED for evaluation. (Patient #2)

The Findings include:

Based on medical record review, staff and physician interviews the hospital failed to provide stabilizing treatment for a patient (Patient #2) who presented to the hospital's DED for evaluation of a foreign body in throat on 01/11/2021.

~cross refer to Stabilizing Treatment, Tag A2407.

Based on medical record review, staff and physician interviews the hospital failed to provide stabilizing treatment for a patient (Patient #2) who presented to the hospital's Dedicated Emergency Department (DED) for evaluation of a foreign body in throat on 01/11/2021.

The findings included:

Closed medical record review on 06/15/2021 revealed Patient #2 was a 56-year-old male who presented to the DED on 01/11/2021 at 0521 for "Object in Throat." Review revealed Patient #2's Medical Screening Exam (MSE) began at 0525. Patient #2's vital signs at 0532 were: pulse (P) 109, respirations (R) 18, and temperature (T) 97.7, and blood pressure (BP) 172/113. Review revealed at 0532 orders were placed for saline lock IV, pantoprazole (Protonix) 40mg (milligram) injection, glucagon 1mg injection, Lorazepam (Ativan) 1mg injection, and XR (chest x-ray) Chest Ap portable. Review of the updated chief complaint at 0532 revealed "Foreign Body in Throat (patient states he has bacon stuck in throat, has taken total 0.75 xanax)." Review of the Nursing Focused Assessment (Registered Nurse -RN #1) at 0534 revealed Patient #2's airway was "Within Defined Limits" and "Patent." Review of the Nursing Comprehensive Neuro Assessment (RN #1) at 0536 revealed Patient #2 was Alert & Oriented x4 and had clear speech. Review of the Emergency Department (ED) provider note (Medical Doctor - MD #1) dated 01/11/2021 at 0606 revealed "Chief Complaint-Patient presents with -Foreign Body in Throat...Bacon last night. Unable to swallow liquid since. H/O (history of) same. Has seen GI in the past. ?possible (sic) future stretch recommendation. Tried Xanax and coke prior to arrival without relief...Difficulty Swallowing. This is a new problem. The current episode started 6 to 12 hours ago. The problem occurs constantly...Nothing aggravates the symptoms. Nothing relieves the symptoms. He has tried water for the symptoms. The treatment provided no relief...h/o similar in the past...Imaging: XR CHEST AP PORTABLE...Impression: 1. Mild left basilar opacities. 2. No radiopaque foreign bodies are identified...MDM Number of Diagnoses or Management Options Foreign body sensation in throat Diagnosis management comments: Medications...0700 am Care turned over to Dr. (Named-MD #2) at shift change for remainder of assessment and disposition..." Review revealed at 0620 & 0621 Protonix 40mg, Glucagon 1 mg, Ativan 1mg and Zofran 4mg were administered. Review revealed at 0645 Clonidine 0.2mg was held due to "patient unable to swallow at this time, bp (blood pressure) improved." Review of the Nursing HEENT (Head, Eyes, Ears, Nose and Throat) Assessment (RN #2) at 0702 revealed "pt reports he has bacon stuck in his throat and isnt (sic) able to drink anything without vomiting it back up. happened yesterday around 1730." Review of the Nursing Respiratory Assessment (RN #2) at 0703 revealed Patient #2's airway was Patent, Bilateral Breath Sounds were clear, and no cough was present. Review revealed MD #2 ordered a GI cocktail (or solution) 30 ml plus lidocaine viscous 2.5% mL, Reglan 10mg injection: and Benadryl 12.5 mg injection. Review revealed at 0832 the GI cocktail was administered and documented by RN #2 "Pt took GI cocktail, vomited shortly after. MD aware." Review revealed the Reglan and Benadryl were administered at 0833 via IV. Review revealed RN #2 documented "Pt and support person understand discharge instructions and follow up care. Pt is alert, oriented x4 and ambulatory." Patient #2 was discharged on 01/11/2021 at 0857.

Review revealed Patient #2 presented to Hospital B on 01/11/2021 at 1235 for an outpatient endoscopy. Review of the Physician H&P dated 01/11/2021 at 1322 revealed "Assessment:1. Dysphagia. 2. Sialorrhea, suspicion for esophageal food impaction since last night. Plan: 1. Endoscopy for possible esophageal foreign body removal..." Review revealed Patient #2 underwent an upper GI endoscopy on 01/11/2021 and successful removal of food impaction was achieved. Patient #2 was discharged home on 01/11/2021 at 1424.

Interview on 06/16/2021 at 0944 with RN #1 revealed she recalled Patient #2's breathing "was good, no distress noted." Interview revealed Patient #2 had the sensation of the bacon being lodged in his throat. Interview revealed at shift change Patient #2 was waiting for the physician to determine his disposition. RN #1 stated she did not recall if the MD consulted a gastroenterologist.

Interview on 06/16/2021 at 1022 with MD #2 (oncoming MD) revealed he did not recall consulting a gastroenterologist. Interview revealed medications had been administered to help relax Patient #2's esophagus and he was being observed and monitored for response of the treatment. MD #2 stated he recalled evaluating Patient #2 and did not recall him being in any distress. Interview revealed MD #2 reviewed the radiology report but not the actual image itself. MD #2 stated he did not document a progress note on Patient #2 but didn't recall any issues. MD #2 stated his normal practice was to document on his patients, however he was unsure why he didn't document on Patient #2. Interview revealed MD #2 was unaware of any additional diagnostics that could have been performed to rule out the bacon still being lodged in Patient #2's esophagus. Interview revealed usually if a nurse reported an issue with a patient to MD #2, he would keep the patient and re-evaluate him before discharging the patient. MD #2 did not recall a nurse reporting an issue with Patient #2 vomiting the GI cocktail up right after administration. Interview revealed MD #2 felt Patient #2 was stable for discharge and follow-up with his gastroenterologist.

Interview on 06/16/2021 at 1049 with MD #1 (initial MD) revealed she did not recall Patient #2 having any issues swallowing. MD #1 stated Patient #2 had a history of stricture and was reporting pain when swallowing. Interview revealed MD #1 stated, "I don't recall reviewing it (chest x-ray) at all, I may have." MD #1 stated food was not radiopaque therefore it would not show up on x-ray. MD #1 stated a chest x-ray was usually not a diagnostic test for foreign bodies of food. Interview revealed usually with the medications given, the medications relax the esophagus and the food usually passes on its own. MD #1 explained Patient #2 could have also been having esophageal spasms and those medications would also help treat the spasms. Interview revealed if a patient had hypersalivation and/or unable to swallow their own secretions or difficulty breathing, she would consult GI services and an emergent endoscopy would be performed. MD #1 stated Patient #2 did not present with those symptoms therefore he could follow-up with his GI MD within 24 hours.

Interview on 06/16/2021 at 1400 with RN #2 (oncoming RN) revealed she recalled Patient #2 reported he had bacon lodged in his throat. Interview revealed the RN received report at shift change and it was reported Patient #2 was going for a procedure to remove the bacon however the procedure got canceled and Patient #2 was discharged instead. Interview revealed RN #2 reported to MD #2 that Patient #2 vomited the GI cocktail up following administration. RN #2 stated MD #2 told her Patient #2 needed to follow-up with his GI MD. RN #2 did not recall if a GI consult was placed at the hospital.