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Based on document review and staff interviews, the hospital staff failed to follow their policies when the staff did not provide an appropriate medical screening examination for 1 of 25 sampled Emergency Department (ED) patients receiving services from the hospital's two dedicated Emergency Departments (ED) from 5/1 to 11/17/14 (Patients #5). When the patient presented with nausea and vomiting of feculent (fecal) material, staff failed to complete abdominal x-rays to rule out a possible bowel obstruction even though the staff knew the patient had a history of bowel obstructions and a recent surgical procedure for a bowel obstruction.

Failure of the staff to provide an appropriate medical screening exam for Patient #5 allowed the patient's condition to worsen to a life-threatening condition from which the patient died.

Findings include:

1. This hospital has a remote location of a hospital which is located on its West Campus. The West Campus hospital is a full service hospital with a dedicated ED. Patient #5 presented at the ED at the hospital on the West Campus in need of emergency services for an emergency medical condition.

2. Review of the hospital policy "EMTALA-(Emergency Medical Treatment and Labor Act)," revised 8/15/2014, revealed in part, "2. Scope of Examination- Individuals presenting to a Genesis DED (dedicated emergency department) must be provided a MSE (Medical Screen Exam) appropriate to the individual's presenting signs and symptoms, as well as the capability and capacity of the Genesis DED. The MSE can involve a wide spectrum of actions ranging from a simple process of obtaining a brief history and physical examination to a complex process involving ancillary studies and procedures such as lumbar punctures, laboratory testing, CT scans and/or other diagnostic tests and procedures.

Refer to A 2406.

Based on medical record review and staff interview, hospital staff failed to provide an appropriate medical screening examination for 1 of 25 sampled Emergency Department (ED) patients receiving emergency services between 5/1/14 to 11/17/14 selected from each of two dedicated EDs it operates (Patients #5). The patient presented with nausea and vomiting of feculent (fecal) odor material. Staff failed to complete abdominal x-rays to rule out a possible bowel obstruction even though they were aware the patient had a history of bowel obstructions and had undergone a recent surgical procedure for a bowel obstruction in September of 2014.

Failure of the staff to provide an appropriate medical screening exam for Patient #5 allowed the patient's condition to worsen. The patient died at the hospital on 11/10/14 during the admission process.

Findings include:

1. This hospital has a remote location of a hospital which is located on its West Campus. The West Campus hospital is a full service hospital with a dedicated ED.

2. Patient #5 medical record revealed the patient had a history of bowel obstructions and had undergone a recent surgical procedure for a bowel obstruction in September of 2014.

a. Patient #5 medical record revealed he presented at the ED at the hospital on the West Campus in need of emergency services for an emergency medical condition on 11/8/14 for difficulty breathing. The patient was diagnosed with pneumonia and discharged in stable condition with medications to the group home where he lived.

b. Patient #5's medical record revealed he presented to the West Campus ED again on 11/9/14 at 5:03 PM with complaints of nausea and vomiting. The patient had vomited twice prior to arriving in the ED and the characteristic odor of the vomit smelled like a bowel movement as reported by the patient's caregiver. Practitioner A, Family Nurse Practitioner (FNP) documented the patient's abdomen as soft, non-tender, no distention and normal bowel sounds. Practitioner A ordered lab tests for a complete metabolic panel, complete blood count and a chest x-ray. Practitioner A discharged Patient #5 home on an anti-emetic medication to reduce nausea in stable condition. Practitioner A failed to complete x-rays of the patient's abdomen although he aware of the feculent odor vomitus.

c. The patient's medical record revealed the patient returned to the West Campus ED on 11/0/14 around 6:00 PM with complaints of difficult breathing. He was evaluated and treated. Patient #5 died during the process of admission to the hospital on 11/10/14.

3. The following interviews were conducted during the onsite investigation.

a. During an interview on 11/18/14 at 2:40 PM, Practitioner A stated Patient #5 presented to the ED with complaints of nausea and vomiting on 11/9/14. The patient's caregiver informed Practitioner A the staff at the group home where the patient lived said the vomitus smelled like "poop" in the bathroom. The caregiver did not say the vomitus was fecal in nature. Practitioner A said he evaluated and treated the patient's pneumonia but did not pursue abdominal x-rays because the information about the feculent vomitus was third hand information from the group home staff. Practitioner A said if the vomitus was feculent, this could be a sign of a bowel obstruction. Practitioner A said he was aware Patient #5 had a history of bowel obstruction and in retrospect should have ordered abdominal x-rays to rule out a possible bowel obstruction.

b. During an interview on 11/18/14 at 1:35 PM, Practitioner B, Doctor of Osteopathy (DO) stated she was consulted on 11/9/14 about Patient #5's respiratory concerns by Practitioner A. Practitioner A suggested the patient needed placement in a facility capable of respiratory therapy since the patient had presented 2 days in succession with the same complaint. Practitioner B said Practitioner A did not report the patient had feculent odor vomitus. Practitioner B said feculent vomitus could be a sign of a bowel obstruction and with Patient #5's history of bowel obstruction, abdominal x-rays should have been completed to rule out bowel obstruction.

c. During an interview on 11/18/14 at 11:55 AM, Staff A, Registered Nurse (RN) stated Patient #5 presented to the ED on 11/9/14 with complaints of nausea and vomiting. A caregiver from the patient's group home relayed the history of the patient's complaint. The caregiver did not tell Staff A the patient's vomitus was feculent. Staff A reported feculent vomit can be a sign of bowel obstruction and the Practitioners generally order abdominal x-rays to rule out an obstruction.

d. During an interview on 11/18/14 at 10:30 AM, Practitioner C, DO stated if a patient presents to the ED with feculent vomitus, or emesis smelling like bowel movement, this could be a sign of a bowel obstruction and he orders abdominal x-rays.

e. During an interview on 11/18/14 at 11:45 AM, Practitioner D, Medical Doctor (MD) stated if a patient presents to the ED with feculent vomitus, or emesis smelling like bowel movement, this could be a sign of a bowel obstruction and he orders abdominal x-rays.

Based on document review and staff interviews, the hospital staff failed to follow their policies when the staff did not provide an appropriate medical screening examination for 1 of 25 sampled Emergency Department (ED) patients receiving services from the hospital's two dedicated Emergency Departments (ED) from 5/1 to 11/17/14 (Patients #5). When the patient presented with nausea and vomiting of feculent (fecal) material, staff failed to complete abdominal x-rays to rule out a possible bowel obstruction even though the staff knew the patient had a history of bowel obstructions and a recent surgical procedure for a bowel obstruction.

Failure of the staff to provide an appropriate medical screening exam for Patient #5 allowed the patient's condition to worsen to a life-threatening condition from which the patient died.

Findings include:

1. This hospital has a remote location of a hospital which is located on its West Campus. The West Campus hospital is a full service hospital with a dedicated ED. Patient #5 presented at the ED at the hospital on the West Campus in need of emergency services for an emergency medical condition.

2. Review of the hospital policy "EMTALA-(Emergency Medical Treatment and Labor Act)," revised 8/15/2014, revealed in part, "2. Scope of Examination- Individuals presenting to a Genesis DED (dedicated emergency department) must be provided a MSE (Medical Screen Exam) appropriate to the individual's presenting signs and symptoms, as well as the capability and capacity of the Genesis DED. The MSE can involve a wide spectrum of actions ranging from a simple process of obtaining a brief history and physical examination to a complex process involving ancillary studies and procedures such as lumbar punctures, laboratory testing, CT scans and/or other diagnostic tests and procedures.

Refer to A 2406.

Based on medical record review and staff interview, hospital staff failed to provide an appropriate medical screening examination for 1 of 25 sampled Emergency Department (ED) patients receiving emergency services between 5/1/14 to 11/17/14 selected from each of two dedicated EDs it operates (Patients #5). The patient presented with nausea and vomiting of feculent (fecal) odor material. Staff failed to complete abdominal x-rays to rule out a possible bowel obstruction even though they were aware the patient had a history of bowel obstructions and had undergone a recent surgical procedure for a bowel obstruction in September of 2014.

Failure of the staff to provide an appropriate medical screening exam for Patient #5 allowed the patient's condition to worsen. The patient died at the hospital on 11/10/14 during the admission process.

Findings include:

1. This hospital has a remote location of a hospital which is located on its West Campus. The West Campus hospital is a full service hospital with a dedicated ED.

2. Patient #5 medical record revealed the patient had a history of bowel obstructions and had undergone a recent surgical procedure for a bowel obstruction in September of 2014.

a. Patient #5 medical record revealed he presented at the ED at the hospital on the West Campus in need of emergency services for an emergency medical condition on 11/8/14 for difficulty breathing. The patient was diagnosed with pneumonia and discharged in stable condition with medications to the group home where he lived.

b. Patient #5's medical record revealed he presented to the West Campus ED again on 11/9/14 at 5:03 PM with complaints of nausea and vomiting. The patient had vomited twice prior to arriving in the ED and the characteristic odor of the vomit smelled like a bowel movement as reported by the patient's caregiver. Practitioner A, Family Nurse Practitioner (FNP) documented the patient's abdomen as soft, non-tender, no distention and normal bowel sounds. Practitioner A ordered lab tests for a complete metabolic panel, complete blood count and a chest x-ray. Practitioner A discharged Patient #5 home on an anti-emetic medication to reduce nausea in stable condition. Practitioner A failed to complete x-rays of the patient's abdomen although he aware of the feculent odor vomitus.

c. The patient's medical record revealed the patient returned to the West Campus ED on 11/0/14 around 6:00 PM with complaints of difficult breathing. He was evaluated and treated. Patient #5 died during the process of admission to the hospital on 11/10/14.

3. The following interviews were conducted during the onsite investigation.

a. During an interview on 11/18/14 at 2:40 PM, Practitioner A stated Patient #5 presented to the ED with complaints of nausea and vomiting on 11/9/14. The patient's caregiver informed Practitioner A the staff at the group home where the patient lived said the vomitus smelled like "poop" in the bathroom. The caregiver did not say the vomitus was fecal in nature. Practitioner A said he evaluated and treated the patient's pneumonia but did not pursue abdominal x-rays because the information about the feculent vomitus was third hand information from the group home staff. Practitioner A said if the vomitus was feculent, this could be a sign of a bowel obstruction. Practitioner A said he was aware Patient #5 had a history of bowel obstruction and in retrospect should have ordered abdominal x-rays to rule out a possible bowel obstruction.

b. During an interview on 11/18/14 at 1:35 PM, Practitioner B, Doctor of Osteopathy (DO) stated she was consulted on 11/9/14 about Patient #5's respiratory concerns by Practitioner A. Practitioner A suggested the patient needed placement in a facility capable of respiratory therapy since the patient had presented 2 days in succession with the same complaint. Practitioner B said Practitioner A did not report the patient had feculent odor vomitus. Practitioner B said feculent vomitus could be a sign of a bowel obstruction and with Patient #5's history of bowel obstruction, abdominal x-rays should have been completed to rule out bowel obstruction.

c. During an interview on 11/18/14 at 11:55 AM, Staff A, Registered Nurse (RN) stated Patient #5 presented to the ED on 11/9/14 with complaints of nausea and vomiting. A caregiver from the patient's group home relayed the history of the patient's complaint. The caregiver did not tell Staff A the patient's vomitus was feculent. Staff A reported feculent vomit can be a sign of bowel obstruction and the Practitioners generally order abdominal x-rays to rule out an obstruction.

d. During an interview on 11/18/14 at 10:30 AM, Practitioner C, DO stated if a patient presents to the ED with feculent vomitus, or emesis smelling like bowel movement, this could be a sign of a bowel obstruction and he orders abdominal x-rays.

e. During an interview on 11/18/14 at 11:45 AM, Practitioner D, Medical Doctor (MD) stated if a patient presents to the ED with feculent vomitus, or emesis smelling like bowel movement, this could be a sign of a bowel obstruction and he orders abdominal x-rays.