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BOTHWELL REGIONAL HEALTH CENTER 601 E 14TH ST SEDALIA, MO 65302 April 27, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview and review of Emergency Department (ED) logs, 72 Hour Return logs, Medical Records, Staffing and Physician On-Call Schedules, the facility failed to provide a sufficient medical screening examination within its capacity and capability for one patient (#14) of 30 patient records reviewed, who presented to the hospital Emergency Department (ED) for emergency care. The patient presented to the hospital with complaints of severe left sided chest pain radiating to his left jaw and stated that he had vomited once.

The hospital had the capacity and capability to complete a medical screening examination to include further assessment of the patient's signs and symptoms of severe chest pain radiating to the jaw to ensure that the patient was not suffering from a medical emergency. There was no indication that the patient's chest pain was resolved at the time of discharge.

Refer to A2406 for details.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to provide a medical screening examination sufficient to determine the presence of a medical emergency within its capacity and capability for one patient (#14) of 30 patients' records selected from January 2015 through April 25, 2016. The Emergency Department (ED) has an average of 3701 emergency visits per month.

Findings included:

1. Record review of the facility's policy titled, "Medical Screening Examination (MSE)," revised 09/2014, showed the following direction:
- The initial triage is completed by a Registered Nurse (RN).
- Individuals presenting to the Emergency Department (ED) for care receive a Medical Screening Exam to determine presence of an Emergency Medical Condition (EMC).
- The MSE is performed by a physician or a mid-level provider.
- The MSE can include the following pre-ED information, ED information and post ED information for up to 48 hours after patient discharge.

Review of the facility policy titled, "EMTALA - Emergency Department Mission/Obligation," revised 09/2014, showed that an Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain), such that the absence of immediate medical attention could reasonable be expected to result in serious impairment to any bodily functions and/or serious dysfunction of any bodily organ or part. Acute, undiagnosed pain is defined by law as an Emergency Medical Condition.

2. Review of the patient's medical record showed that the patient (MDS) dated [DATE] at 4:38 PM with complaints of severe chest pain that radiated to his left jaw and was pale and diaphoretic (sweating heavily). He stated that he had vomited prior to arrival at the ED. He was assigned a triage priority of two which was Emergent, which indicates a high risk situation; confused/lethargic/disoriented; or in severe pain or distress requiring medical attention within minutes. A danger exists to the patient if medically unattended.

3. Review of the ED Triage Assessment by Staff R, Triage RN, on 01/19/15 at 4:38 PM showed:
- Pain intensity a nine (0 being the least pain and 10 being the most severe pain);
- Patient is awake, alert, appropriate and oriented times three (person, place and time);
- Temperature 97.7 (normal 98.6);
- Heart rate 98 and regular by the monitor;
- Blood pressure 139/72 by the automatic cuff while patient lying down;
- Height 5' 10" and weight 165 lbs;
- Medication history: Zoloft (an antidepressant) and Concerta (a stimulant for treating attention deficit hyperactivity disorder).

4. Review of the Cardiac Assessment performed by Staff M, Primary RN, on 01/19/15 at 4:38 PM showed:
- The patient presented to the ED with severe left sided chest pain that radiated to the left jaw;
- The patient was pale and diaphoretic.
- His pain was of one to three hours duration and was a 10 at onset.
- He reported his pain intensity as 10 upon arrival to the ED at 4:38 PM.
- He reported nausea, vomiting and diaphoresis (sweating heavily).
- He reported pain with physical exertion.
- He took a 324 mg aspirin at home.
- Heart rate was 85.
- Heart rhythm was a sinus rhythm (normal heart rate and rhythm) by telemetry.

5. Review of the ABC/Safety Assessment by Staff M, 01/19/15 at 4:38 PM showed:
- The patient had been brought to the facility by private vehicle by a friend and was ambulatory.
- His breathing was regular and non-labored and his lung sounds were clear.
- His skin was pale, cool and diaphoretic.
- He was a current smoker and his dependence was high.
- He used Marijuana (a psychoactive drug) and Methamphetamine (Meth, an illegal and highly addictive drug).
- Aware of person, place, time and situation.
- History of Obsessive Compulsive Disorder and on medication.
- History of Attention Deficit Disorder (ADD, a short attention span and impulsive).
- He denied headache, dizziness or loss of consciousness.
- No slurred speech, or facial droop.
- Equal Hand Grips and moved all extremities, pupils equal, round and reactive to light, with brisk pupil reaction.

During an interview on 04/26/16 at 1:47 PM, Staff M stated that she was the primary nurse for the patient. She stated that:
- The patient presented with complaints of severe left chest pain that radiated to his left jaw and he was pale, cool and diaphoretic.
- He stated that he had vomited before arriving in the ED.
- A cardiac assessment was performed and was negative.

During an subsequent interview on 05/11/16 at 1:15 PM, Staff M, stated that:
- She did not witness vomiting by the patient or he would have been given an antiemetic (drug given for vomiting and nausea) and she was not aware that the patient vomited while in the waiting room.
- He had a slightly elevated white blood count but was without fever.
- He denied using any drugs in the previous 72 hours.
- The drug screen came back as positive for meth, opioids (narcotic pain medication) and cannabis.
- Continuous blood pressures were taken by the automatic cuff and there was no concerns as they were "normal".
- He had been given morphine approximately two hours before discharge and his pain intensity was a two at the time of discharge.
- He was discharged and she walked him to the check out desk.

Staff documented two blood pressure readings in the medical record; one at admission and one at discharge but no other evidence of blood pressure readings were documented throughout the ED visit.

6. Review of the treatments administered to the patient on 01/19/15 showed:
- 4:34 PM: Blood drawn for Complete Blood Count showed White Blood Cells (indication of infection) at 11.90 (normal range is 0.4. - 10.8);
- 4:38 PM: Blood pressure monitor, cardiac monitor, Oxygen per nasal cannula (in the nose), pulse oximetry (measures oxygen in the blood) were in place;
- 4:45 PM: Troponin level was 0 or negative (measures for levels of protein in the blood which indicates heart muscle damage);
- 5:05 PM: Nitroglycerin (Nitro, tablets to treat chest pain) SL (under the tongue) 0.4 mg (pain 10 at 5:01 PM);
- 5:10 PM: Nitro SL 0.4 mg (pain a 10 at 5:10 PM);
- 5:27 PM: Nitro SL 0.4 mg (pain a 10 at 5:27 PM);
- 5:27 PM: Morphine (a narcotic pain medication) 2 mg IVP (Intravenous push, medication given at a slow rate (pain a 10).
- 5:27 PM: Ativan (medication used for anxiety) 10 mg IV;
- 5:27 PM: Toradol (a non-steroid anti-inflammatory which helps to decrease swelling, pain or fever) 30 mg IVP (facial grimacing; pain 10);
- 6:30 PM: pain at a four;
- 7:05 PM: Troponin level repeated and was 0;
- 8:13 PM: Blood pressure was 119/65.

The medical record did not contain documentation of the patient's vital signs taken before, during or after he received the three nitroglycerin tablets, or IV Toradol and Ativan.

Review of the chest x-ray findings dated 01/19/15 showed:
- The lung fields to be fully expanded and clear of active infiltration (pneumonia) or consolidation (filling of lungs with fluid).
- The heart size is borderline enlarged and the aorta is mildly atherosclerotic (thickened artery wall).
- No active lung disease.

Staff Q did not obtain further testing, for example, a CT scan (Computed Tomography-detailed images of internal organs by x-rays) to investigate the patient's enlarged heart and artherosclerotic aorta or complaints of severe chest pain radiating to the jaw (signs of a thoracic aortic aneurysm).

7. Review of the Medical Screening Examination dated 01/19/15 at 8:04 PM showed:
- The patient complained of sharp chest pain that radiated to his left jaw and was pale and diaphoretic.
- He was anxious and hyperventilating (breathing at an abnormal rapid rate).
- He stated that he had vomited once.
- He related some substance abuse including Meth
Past Medical History:
- No history of: Cardiac disorders, endocrine disorders, diabetes, respiratory disorders, cerebrovascular accidents, gastrointestinal disorders or musculoskeletal disorders.
Physical Exam:
- A patient in moderate distress with clear lungs;
- Chest tender on palpation;
- The heart rate was regular and rhythm with no gallop, no JVD (jugular vein distention, the visible "bulging" of the external jugular veins on either side of the neck), no murmur (an extra or unusual sound heard during a heartbeat);
Progress:
- Cardiac Enzymes (measure the levels of enzymes and proteins that are linked with injury of the heart muscle) times two were negative. Electrocardiogram (EKG, test that checks for problems with the electrical activity of the heart) had no acute changes.
Departure:
- Diagnosis of chest wall pain: Pleurisy (inflammation of the tissue layers lining the lungs and inner chest wall) with condition improved.
- Prescriptions given for Ibuprofen (an anti-inflammatory), Norco (medication for pain) and Z pack (an antibiotic).

During a telephone interview on 04/26/16 at 10:52 AM, Staff Q, ED Physician, stated that:
- The patient was highly anxious and uncomfortable.
- A cardiac work up was done and was negative.
- The EKG was normal.
- The patient stated that he had vomited once.
- The patient stated he was not a smoker.
- The patient stated that he used Meth.
- The patient was discharged and was without cardiac symptoms.

During an interview on 05/12/16 at 7:15 AM, Staff Q, stated that:
- The cardiac work up was negative and the focus was then on his chest pain.
- The blood pressure of 119/65 was of no concern.
- There were no acute cardiac changes.
- The patient was afebrile (no fever).

During a telephone interview on 05/24/16 at 9:09 AM, Staff Q, stated that:
- The patient gave a poor history due to his anxiety and there was no one with him to give an extended history.
- Therefore, no risk factors were apparent for cardiac disease.
- The common things were ruled out such as heart attack.
- There was no pneumonia or congestion by x-ray.
- The patient's oxygenation was good.
- Marfan's syndrome (a genetic connective tissue disorder that can cause the aorta to dissect or tear) was not considered since the patient did not exhibit the common characteristics.
- The patient's drug use was a consideration for his anxiety, hyperventilation, pallor (pale appearance) and diaphoresis.
- The patient had made a 180 degree turn around since his admission and was no longer pale, anxious, hyperventilating or diaphoretic.

Staff Q failed to determine the cause of the patient's severe chest pain that radiated to his jaw before he discharged the patient from the ED.

8. Review of the physician's Call Schedule showed a cardiologist was on call on 01/19/15 when the patient presented to the ED.

Review of the medical record showed that Staff Q did not consult the on-call Cardiologist related to the patient's severe chest pain that radiated to the jaw.

9. Review of the Complex Discharge Instructions at 8:42 PM showed:
-Pain intensity: two;
-Temperature: 97.6;
- Heart rate: 76 (normal is 60 - 100 beats a minute);
- Respiratory rate: 19;
- Blood pressure: 119/65;
- O2 Saturation (oxygen in the blood) 100 % on room air;
- Patient pink warm and dry with no signs and symptoms of distress.

10. The patient died the night of 01/20/15 after collapsing at his home.

11. Review of the Medical Examiner's (ME) autopsy report dated 03/25/15 showed:
- In the ME's opinion, the cause of patient # 14's death was a dissecting aortic aneurysm (a tear in the lining of the artery causing blood to leak) which resulted in a pericardial tamponade (blood fills between the membranes lining heart keeping the heart from functioning). "These findings and the general appearance of the deceased (patient # 14) suggest strongly that he had the Marfan's Syndrome."
- The toxicology report (the result of lab procedures identifying and quantifying potential toxins, including prescription medications and drugs of abuse and interpretations of the findings) was positive for meth, opioids and cannabis.

During a telephone interview on 05/30/16 at 1:30 PM, the Medical Examiner, stated that:
-The patient had an elongated face (Collie face) which was typical of Marfans.
- He suspected Marfans and it was confirmed when he opened up the patient's chest and saw the heart.
- The toxicology report showed that Methamphetamine was over 5 micrograms/ml which is high and could have caused the dissection.