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ST JOSEPH MEDICAL CENTER 1401 ST. JOSEPH PARKWAY HOUSTON, TX 77002 March 21, 2016
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to provide an appropriate medical screening examination to one of six sampled patients who presented with a diagnosis of alcohol withdrawal (Patient # 1).

Patient # 1 presented on [DATE] with a history of stopping drinking two (2) days prior. Reported daily consumption 1.75 liters of vodka. History of Bipolar Disorder (on Lithium) and Hypertension, according to the medical record.

Medical screening examination failed to include any laboratory work. Patient # 1 was "medically screened out" (MSO) and found dead in the ER lobby bathroom a few hours later.

Findings include:

TX

Record review of the Emergency Medical Services (EMS) Patient Care Report (ambulance run sheet), dated 03-13-16 (time 1352) read: "[AGE] year old male complained of weakness...stated he was having withdrawals from alcohol, with headache and body aches. Pt showed signs of sweating and weakness...pt reported he had vomited earlier...skin clammy..."

Record review of Patient # 1's Emergency Department (ED) clinical record (03-13-16) revealed the following timeline:

Arrival time (EMS) : 14:20
Triage complete: 14:23
Medical screen exam (MSE) : 14:37
Discharge order by MD: 14:41

Triage Assessment:

Further review of Patient # 1's ED record revealed the Triage assessment included the following information:

Diagnosis: Alcohol (ETOH) Withdrawal

*Patient states stopped drinking alcohol 2 days ago. Was drinking 1.75 liters of vodka a day...'I feel out of it.' "

*Past medical history included "Bipolar Disorder and Hypertension."

*Home medication was listed as Lithium.

*Vital signs: blood pressure 104/58, heart rate 70; respirations 20 : recorded at 1426 by Triage Registered Nurse (RN). These were the exact same vital signs as documented on the EMS ambulance run sheet at 1420.

Triage acuity level was: Emergency Severity Index (ESI) - 3 Urgent

Interview on 03-21-16 at 11:45 a.m. with ED Director # 13, she stated when a patient is assigned an acuity level of "ESI Level 3 - Urgent" this meant they required 2 or more resources (lab or other testing) and a more in-depth evaluation.

Medical Screen Examination:

Further review of Patient # 1's clinical record revealed Patient # 1 received a MSE by ED Physician # 7 at 1437. The following information was included in the patient interview and exam documentation:

*"Thirty-one (31) year old male with history of alcohol abuse, stopped drinking 2 days ago, complaining of fatigue and exhaustion... believes he is going through withdrawal.
* Symptoms occurred just prior to arrival.... mild and unchanged.
* Patient has not recently seen a physician.
* Past medical history: Bipolar Disorder and Hypertension.
* Home medication: Lithium
* Patient alert; skin was warm & dry.
* Impression: discharged to Home - MSO (medically screened out) - Alcohol (ETOH) Withdrawal."

There was no laboratory work ordered by the physician.

Interview on 03-17-16 at 11:45 a.m. with ED Physician # 7 she stated she saw Patient # 1 on 03-13-16 as he arrived by ambulance. She spoke with the ambulance crew and asked about the patient's vital signs. Physician # 7 said "this patient did not present the typical signs of alcohol withdrawal of "shakiness, anxiety, or sweating. When I saw him he was stable. He did not look as if he was going through withdrawal."

Physician # 7 stated she told the Triage nurse she wanted this patient to go to a "sobering center." There was no physician order for this or mention of this in the physician documentation.

She went on to say, later after reviewing the ambulance run sheet; Physician # 7 noted EMS had documented the patient had clammy skin and had vomited earlier. She said the ambulance run sheet had not been available to her when she saw the patient.

Physician # 7 said although Patient # 1 had a history of Bipolar Disorder; Hypertension; and was taking Lithium; the medical screening examination was appropriate. "His vital signs were normal and based on his presentation - he looked great."

Of note: the vital signs documented in the MSE were the exact same vital signs as recorded by EMS after arrival at 1420.

Review of facility policy titled "Medical Screening", dated 12-10-14, read: "...Medical Screening Examination: is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists... The MSE is an ongoing process and the medical record must reflect continued monitoring based on the patient's needs..."

Review of facility policy titled "Emergency Department Triage", dated 02-01-2016, read: "Procedure: a registered nurse triages each patient and determines the priority of care based on physical, development, psychosocial needs and patient flow through the ED. All patients...are triaged by a nurse upon arrival...III. Level III Urgent-need for two or more resources-not risk for deterioration..."
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to appropriately transfer one of six sampled patients who presented with a diagnosis of alcohol withdrawal (Patient # 1).

Patient # 1 presented on [DATE] with a chief complaint of "alcohol withdrawal." Reported daily consumption 1.75 liters of vodka. History of Bipolar Disorder (on Lithium) and Hypertension, according to the medical record.

Patient # 1 discharged home from the Emergency Department (ED) and found dead in the hospital lobby restroom three hours later.

TX

Record review of Patient # 1's ED clinical record (03-13-16) revealed he presented on [DATE] with a chief complaint of "alcohol withdrawal." Reported daily consumption 1.75 liters of vodka. History of Bipolar Disorder (on Lithium) and Hypertension, according to the medical record.

ED Timeline:

Arrival time (EMS) : 14:20
Triage complete: 14:23
Medical screen exam (MSE) : 14:37
Discharge order by MD: 14:41

Medical Screening Exam:

The following information was included in the patient interview and exam documentation:

*"Thirty-one (31) year old male with history of alcohol abuse, stopped drinking 2 days ago, complaining of fatigue and exhaustion... believes he is going through withdrawal.
* Symptoms occurred just prior to arrival.... mild and unchanged.
* Patient has not recently seen a physician.
* Past medical history: Bipolar Disorder and Hypertension.
* Home medication: Lithium
* Patient alert; skin was warm & dry.
* Impression: discharged to Home - MSO (medically screened out) - Alcohol (ETOH) Withdrawal."

There was no laboratory work ordered by the physician.

Physician # 7 stated she told the Triage nurse she wanted this patient to go to a "sobering center." There was no physician order for this or mention of this in the physician documentation.

Interview on 03-17-16 at 2:25 PM with Registration Clerk # 14 said she noted in the computer that Patient # 1 had been discharged before she had even completed his registration. When she went to obtain information and consents, Patient # 1 asked her: 'when is the doctor going to see me?' Registration Clerk # 14 said "he was sitting in the lobby in a chair (EMS had put him there). He was sweating, eyes were yellow and bulging. He seemed to be in a sense of panic. He kept asking are they coming to see me?"

Registration Clerk # 14 reported " I was so concerned this patient was being discharged , I went to my supervisor. I told her how this man was sweating and eyes bulging. I told my supervisor 'this is ridiculous to discharge him home.'"

Record review of clinical record ( # 2) of Patient # 1 : nurse's notes:" 03-13-16 (2000) :pt found in Men's bathroom sitting on the toilet at 1950 by bystander; pt not breathing; no pulses, cold skin; mottled skin, dilated right pupil. CPR started, MD at bathroom and pt brought into bed # 1...no blood pressure; no pulse; no respirations, body temperature 92.2 (rectal) ;2000: cardiac monitor on. Was pronounced dead.."

Review of facility policy titled "Transfer Policy,"dated 05-28-15, read:: "...Procedure...D. If an individual ...'comes to' an emergency department of a hospital requesting either medical care or emergency medical care and an emergency medical condition is identified, the hospital must provide either: 1. Further medical examination and treatment, including hospitalization , if necessary, as required to stabilize the medical condition... 2. Or a transfer to another more appropriate or specialized facility after providing treatment necessary to minimize the risks to the health of the individual..."