The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

EDWARD WHITE HOSPITAL 2323 9TH AVE N SAINT PETERSBURG, FL July 5, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
A. Based on reviews of clinical records,
policy and procedures and interview it
was determined the facility's emergency
department (ED) physician failed to
complete an appropriate medical
screening examination (MSE)to include
ancillary services routinely available in
the emergency department to
determine whether or not an emergency
medical condition existed for (#1) of 20
sampled patients. Refer to findings in
Tag-A-2406.

B. Based on clinical record review and
policy review it was determined the
facility failed to ensure that stabilizing
treatment was provided to an individual
that was within the capability of the
hospital's ED for (#1) of 20 patients
reviewed with an emergency medical
condition (EMC) was stabilized prior to
discharge. Refer to findings in Tag A-
2407.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on reviews of clinical records, policy and procedure and interview it was determined the facility's emergency department (ED) physician failed to complete an appropriate medical screening examination (MSE) to include ancillary services routinely available in the emergency department to determine whether or not an emergency medical condition existed (#1) of 20 sampled patients.
Findings include:

Review of the "Emergency Patient Record" dated 6/8/2012 revealed that the subject (a 63 year old) of the complaint presented to the emergency department(ED) at 2:08 p.m. The patient was triaged at 2:10 p.m., with a chief complaint of "Chronic leg pain and difficulty walking." The chief complaint was listed as extremity pain/injury. The subjective assessment revealed the patient was complaining of exacerbation of chronic lower extremity pain. She was diagnosed with neuropathy with lower extremity pain for 3 months. The patient also complained of diarrhea for 3 days. The objective assessment revealed the patient was alert and oriented. She was very skinny and disheveled. The patient's vital signs in triage were blood pressure 146/73, pulse 92, respiration 16, oxygen saturation level of 95% on room air and a pain level of 10 on a scale of 0-10 (pain scale rating on scale of 1-10 with 10 being severe). The complaint of pain was to extremity with an onset date of 3/10/12 at 8:00 a.m. The patient was assigned an acuity level of 3, urgent and taken to room in main ED, via wheelchair.
A detailed nursing extremity assessment was completed at 2:14 p.m. The nurse documented the patient had "bilateral lower extremity pain for 3 months and has a history of diabetic neuropathy (diabetic nerve pain can include burning or shooting pain in the feet and legs). The patient was requesting pain medication repeatedly. The physician was made aware. The patient also states she has been having diarrhea for 3 days." A pain assessment was completed at 2:20 p.m. by nursing. A review of the nursing documentation revealed the patient was initially evaluated by the ED physician at 2:25 p.m. The nursing assessment also revealed the pain level was a 10 on a scale of 0-10, has been ongoing ache and burning in bilateral legs. The patient was medicated for the pain at 2:46 p.m. with Demerol (pain medication) 25 milligrams (mg) intramuscularly. A pain reassessment was completed at 3:19 p.m., with the patient reporting a pain level of 5. Further documentation by the ED nurse under the section titled; "Physical Findings" indicated that the patient's "Musculoskeletal Assessment" was an identified problem. The patient was care planned for "Impaired Musculoskeletal Function/Mobility and pain."
Documentation by the ED nurse revealed the patient was discharged home at 3:20 p.m., "...son here to pick her up, Pt. (patient) assisted to w/c (wheelchair)." The patient was given discharge instructions and prescription for Flexeril (a muscle relaxant used to treat musculoskeletal conditions such as pain). The patient was discharged 42 minutes after she was first triaged.

A review of the ED physician's record (no date/time) revealed a chief complaint of bilateral leg pain for years and diarrhea for 3 days. The past medical history was listed as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The physical examination was focused on the extremities. The physician documented the extremities were normal on inspection. Further review under the sections titled, CVA (Cardio Vascular System, respiratory, and Abdomen (GI) (GI -Gastrointestinal) were all left blank, despite this patient having a past medical history of CHF and COPD, and complaint of diarrhea for 3 days. The physician's clinical impression was chronic leg pain and diarrhea. The physician also checked off on this form as reviewing the nursing assessment, which identified this patient as having "Impaired Musculoskeletal/Mobility." There was no documented evidence that the patient's compliant of diarrhea was addressed. There was also no evidence that any diagnostic evaluation was completed to determine whether or not an emergency medical condition existed for this patient (#1) on 6/8/2012.

Review of the ambulance patient care report dated 6/9/12 revealed they arrived at the patient's residence at 12:52 p.m. The chief complaint was listed as "unconscious/fainting" and the primary symptoms were listed as "diarrhea." The primary impression was "syncope (fainting)." The ambulance personnel assessment revealed the "airway was patent, circulations, skin temperature, breathing and skin color were all within normal limits, the central nervous system was intact and lung sounds were clear." The patient's vital signs were blood pressure 120/60, pulse 80, respirations 18, and oxygen saturations 99%. Her level of consciousness was alert and the pain level was 3 out of 10.

Review of the ED record dated 6/9/12, the patient's second visit to the ED, revealed the patient arrived at 1:25 p.m. per ambulance. The patient was triaged at 1:28 p.m. with a stated complaint of "possible syncopal (fainting) episode, nausea, vomiting, diarrhea and feet pain." "The chief complaint was listed as change in mental/neuro status. The patient was assigned an acuity level 3, urgent and placed in a room. The subjective assessment revealed "from home for evaluation of possible syncopal episode this morning, patient states she passed out because she is in so much pain. She complained of bilateral feet pain (neuropathy), a decreased appetite, nausea, vomiting and diarrhea." The patient appears emaciated (extreme weight loss, extremely thin). The objective assessment revealed the patient was alert and oriented times 3, poor skin turgor, skin was pale/warm/dry, weak pedal pulses and moves all extremities. The vital signs were blood pressure 124/61, pulse 89, respirations 22, temperature 97.6 and an oxygen saturation of 97% on room air. The patient's pain level was 10 on a scale of 0-10. The patient was evaluated by the ED physician (same Physician) at 1:29 p.m. An abbreviated NIH (National Institute of Health) stroke scale was completed at 1:37 p.m., which revealed the patient was fully awake, knows both age/birth month. There was no drift observed of the extremity. Documentation also revealed the patient behavior as, "agitated." Further documentation revealed the patient was experiencing "Numbness and tingling: foot, left, foot right ... weakness in Hand, Right, leg, left." A STAT electrocardiogram (EKG) was completed at 1:45 p.m. and the patient was placed on a cardiac monitor. A pain assessment was completed at 1:49 p.m., which revealed the patient's pain level was a 10 on a scale of 0-10. The patient was medicated with Dilaudid (pain medication)1 mg at 1:53 p.m. The patient's pain level was 10 on a scale of 0-10. A detailed nursing assessment was completed at 2:00 p.m. that revealed the patient had a decreased appetite for a few days and increased lethargy per report. A pain reassessment was completed at 3:10 p.m. with a pain level of 0 on a scale of 0-10. Documentation by the ED nurse revealed the patient had a past medical history of, "Cardiac, HTN (Hypertension), Thyroid, Cholesterol, chronic pain, GERD (gastroesophageal reflux disease-heart burn). The vital signs at 3:11 p.m. were blood pressure 122/56, pulse of 112 (normal pulse rate 60-100), respirations 16 and an oxygen saturation level of 97%. A review of the ED nurse's 3:36 p.m. revealed "the patient's family was extremely disgruntled and upset that patient is being discharged home. Patient's primary care physician called and spoke with ED physician regarding family's concerns.

A review of the ED physicians record (no date/time) revealed the chief complaint was bilateral leg pain and passing out from pain. The character of the event was listed as "felt faint." The physical examination revealed all systems were normal. The physician's clinical impression was chronic leg pain. The facility failed to ensure that an appropriate medical screening examination was performed, despite the patient's complaints and the nursing evaluation of 6/9/2012, which revealed a significant change in the patient condition as compared to 6/8/2012, and past medical history. Other than an EKG being performed on this patient on 6/9/2012, there was no documented evidence that further ancillary services such as laboratory tests, (i.e WBC, CBC, urine testing) was performed to determine whether or not an emergency medical condition existed for the patient when she (MDS) dated [DATE]. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that an appropriate medical screening examination was provided depending on the individual's presenting signs and symptoms to determine whether or not an emergency medical condition existed for patient #1 on 6/9/2012.

A review of the subject of the complaint clinical record from another acute care facility revealed on 6/10/12 the patient presented to the ED at 2:23 a.m. The patient was transported by the son. A rapid triage was completed at 2:38 a.m. with a complaint of shortness of breath and foot pain. The patient's triage vital signs were blood pressure 120/72, pulse 103, and respiratory rate 32 (normal respiratory rate for adults 15-20), an oxygen saturation (measure of oxygen level in the blood) level of 89% (normal oxygen saturation is 95-100%) on room air and a pain level of 9 on a scale of 0-10. The patient was assigned an acuity level of 3, urgent. The ED history was entered at 2:41 a.m. A detailed nursing assessment was completed at 3:27 a.m. that revealed the patient was alert and oriented times 3. She was agitated, anxious, impulsive and restless. The patient's respirations were regular, diaphragmatic, in a tripod position and using accessory muscle (neck muscles). The patient's lung sounds were clear and bowel sounds were present. The description of her skin was blotchy, cool, cyanotic and mottled.
A review of the ED physician's documentation revealed the patient was seen "immediately upon arrival."The chief complaint was shortness of breath. The history of present illness was "the patient presents with reports of shortness of breath and foot parasthesias (a skin sensation such as burning, tingling). The patient was reportedly seen at outside facility and discharged . The son reports he started cardiopulmonary resuscitation (CPR) on his mother twice today. Son reports the mother has not been eating much. He does report she has a history of COPD. He reports she has not been smoking in the last week. Patient is a very poor historian. Patient complains of nausea but denies vomiting." A review of the physical examination revealed the gastrointestinal was soft, non-tender, non-distended with normal bowel sounds. The physician's impression and plan was Hypokalemia (low Potassium), Metabolic Acidosis, Sepsis (bacterial infection in the blood stream or body tissues), Ammonia, Elevated cardiac markers, Rhabdomyolysis(rapid breakdown of skeletal muscle), and Acute Renal Failure. The patient's condition was listed as critical and she was admitted at 5:25 a.m. to the Intensive Care Unit.
A review of the Discharge/Death Summary dictated on 6/12/12 at 10:38 a.m. revealed the final diagnosis was septic shock, severe ischemic bowel disease of the complete bowel, severe renal failure, severe metabolic acidosis, shocked liver, respiratory failure, right lower lobe pneumonia, history of congestive heart failure, history of severe hypocalcaemia and lactic acidosis. A review of the death summary revealed "the patient came to the emergency room , brought in by her son after she was found to be lethargic, drowsy and not eating for a long time. The patient was found to be significantly acidotic (increased acidity in the blood and other body tissues) with a pH of 6.9 (normal pH 7.41) and we went ahead and did a CT of the abdomen which showed pneumobilia (gas in biliary system) and distended gallbladder and ileus suggestive of ischemic colitis (inadequate blood flow to the large intestine). The patient had emergency surgery by surgeon who did small bowel resection and resection of ischemic bowel with end-to-end anastomosis. The patient was supposed to go for a repeat exploratory laparotomy to see if she had any residual ischemic bowel. The patient continued to be on a ventilator, on pressors (drugs used to treat severe low blood pressure) and intravenous fluids. Unfortunately, over the last night, the patient became more and more lethargic and the patient went into cardiorespiratory arrest and coded at around 7:50 a.m. this morning. The patient's son was at the bedside."
An interview was conducted on 7/5/12 at approximately 5:00 p.m. with an ED physician. When given the subject of the complaint's clinical scenario and asked how he would have responded to the situation, the physician stated he could not answer that without actually seeing the patient. He indicated each ED physician had a different perspective when evaluating the patient. Only by evaluation could a physician know how to treat each patient that presented to the ED.

Review of the facility's policy, "EMTALA- Florida Medical Screening Examination and Stabilization Policy", policy #ED 02, reviewed 10/11, page 5 of 8, revealed the Extent of the MSE.
1. Determine if an Emergency Medical Condition (EMC) exists- If an EMC is determined to exist, care, treatment or surgery must be provided by a physician as necessary to relieve or eliminate the EMC within the service capability of the facility.
2. An MSE is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The MSE must be appropriate to the individuals presenting signs and symptoms and the capability and capacity of the hospital.
3. The medical record must reflect continued monitoring according to the individuals needs until it is determined whether or not the individual has an EMC and if she/he does, until she/he is stabilized or appropriately transferred.
5. The MSE may vary depending on the individuals signs and symptoms:
a. Depending on the individuals presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that involves performing ancillary studies and procedures.

The facility failed to ensure that an appropriate medical screening examination was conducted on patient #1 on 6/8/2012 and 6/9/2012.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on clinical record reviews and policy review it was determined the facility failed to ensure that stabilizing treatment was provided to an individual that was within the capability of the hospital's ED for (#1) of 20 patients reviewed with an emergency medical condition (EMC) was stabilized prior to discharge. (see Tag A-2406 for additional information regarding patient #1).

Findings Include:


Patient #1 presented to the facility's emergency department(ED) on 6/8/12 and again on 6/9/12. The patient presented with a complex medical history of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure.
On 6/8/12 and 6/9/2012 the patient received an inappropriate medical screening examination. The patient was taken to another acute care facility on 6/10/12 after becoming unresponsive. The second facility completed a comprehensive evaluation and found multiple severe medical problems. The patient was admitted but later expired on [DATE] from septic shock, severe ischemic bowel, renal failure and shocked liver.

The facility failed to provide stabilizing treatment that was within the capabilities of the staff and facilities available at the hospital for further medical examination and treatment as required to stabilize the medical condition for patient #1 on 6/8/2012 and 6/9/2012.


Review of the facility's policy, "EMTALA- Florida Medical Screening Examination and Stabilization Policy", policy #ED- 02, reviewed 10/11, page 8 of 8, revealed Establishing Medical Stabilization.
Paragraph 3-Stable for Discharge-an individual is considered stable for discharge when, within reasonable clinical confidence, it is determined the individual has reached the point where his or her continued care, including diagnostic work up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient.