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KEOKUK COUNTY HEALTH CENTER 23019 HIGHWAY 149 SIGOURNEY, IA 52591 Dec. 20, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on document review and staff interview, the Critical Access Hospital (CAH)'s administrative staff failed to ensure the emergency department (ED) staff followed their policies and provided all available stabilizing treatment to 1 of 21 patients reviewed (Patient #16) who requested emergency medical care at the CAH's ED on 12/4/17. The
CAH administrative staff identified 10 staffed beds, with an average census of 6.7 patients. The CAH had a dedicated ED staffed by a mix of physicians and mid-level practitioners. The CAH staff reported an average of 205 patients presented to the ED per month for the last six months.

Findings included:

The ER call schedule for 12/04/2017 revealed that Staff G PA-C (Physician Assistant-Certified) was the mid-level practitioner on-call and Staff F MD (Medical Doctor) was the back-up physician. The CAH's capabilities included radiology, laboratory, and pharmacy services.

Review of the medical record showed patient # 16 presented on Monday 07:58 AM 12/4/2017 with complaints of persistent cough over past 3 weeks and chest pain radiating from her left shoulder down through her left breast. The mid-level practitioner examined patient # 16 and obtained a chest x-ray, labs and a CT scan of the chest. The lab results showed patient # 16 had a D-Dimer which was significantly elevated to 3,380 (normal range 0-600 ng/ml). A chest CT scan (special type of x-ray) was obtained to rule out a pulmonary embolism. Mid-level practitioner G's note revealed his initial plan of care was to admit patient # 16 because the patient had received multiple rounds of outpatient oral antibiotics without improvements of her respiratory infection. Mid-level practitioner G discussed the case with Medical Doctor F who determined the patient was getting better. Mid-level practitioner G discharged patient # 16 with instructions to take an antibiotic, Azithromycin 500mg daily x 6 doses, continue potassium supplements and to follow-up later this week or next with the clinic.

ED Registered Nurse (RN) A documented in the medical record at 1:38 p.m. on 12/04/2017 that "Provider states that due to shortage of IV fluids, patient will be treated as outpatient", and that patient # 16 was discharged at 2:41 p.m.

Review of a second medical record showed that patient # 16 presented to Hospital B's ED on 12/5/17, approximately 12 hours after dischage from Keokuk County Health Center for treatment of an unstabilized emergency medical condition.

INTERVIEWS

In an interview on 12/19/17 at 4:15 p.m., ED RN A stated that the mid-level practitioner G was going to admit patient # 16 but changed his mind. We've been having a shortage of fluids so he decided not to admit her. Our pharmacist said we have to be careful related to a shortage of 100 ml bags of normal saline, they said not to use the bags if we don't have to. I think it is the fluid to mix the antibiotics with.

In an interview on 12/19/17 at 4:30 p.m. mid-level practitioner G stated that patient # 16 had upper respiratory symptoms for several weeks. I had seen her a time or two before. From my perspective she was not prescribed a high enough dose for the antibiotic. The chest X-ray showed patient # 16 had pneumonia in the left lower lobe. I mentioned to one of the nurses I thought she would be admitted , they had already moved her to a hospital room before I got the CT scan reading. I talked to Dr. F and he said he was fine with what I wanted to do. I concluded after reviewing her antibiotics that it would help if I doubled up on her Z-pack. I called her primary care physician and made sure he would be able to see her for a follow up after a couple days. She had seen multiple practitioners and had multiple antibiotics. She seemed okay with discharge. There was no real pushback. She just seemed a little confused.

In an interview on 12/20/17 at 9:36 a.m. ED RN A stated that mid-level practitioner G said we would keep patient # 16 as an inpatient on IV antibiotics because she had pneumonia. Once I had the ward clerk admit patient # 15, I went to mid-level practitioner G's office, he changed his mind. He had talked to the pharmacist and the Director of Nursing and found we didn't have the IV fluids for the medications he wanted to give. I told patient # 16, if she were to get worse she should seek medical attention again. I told her that it might be in her best interest to go to a larger hospital that had more testing capabilities. The patient returned to the ED on Monday, we transferred her by ambulance to another hospital. She was having increased pain related to rib fractures they found at some point, possibly from the force of coughing for so long.

In an interview on 12/20/17 at 11:15 a.m., the Director of Nursing stated that mid-level practitioner G said he was thinking about admitting patient #16 and giving her two IV antibiotics. I told him before he put his orders into the computer to talk to the pharmacist to make sure we had what we needed to take care of the patient. If she needed to be an inpatient, we would have to transfer to another hospital.

Refer to Tag C2407 for further details.
VIOLATION: STABILIZING TREATMENT Tag No: C2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interviews, the Critical Access Hospital (CAH)'s failed to provide within its capabilities, treatment to stabilize an emergency medical condition of 1 of 21 patients records sampled (Patient #16) who presented to the ED seeking care from June to December 2017. The CAH's capabilities included a dedicated ED staffed by a mix of physicians and mid-level practitioners, radiology, laboratory and pharmacy services. The CAH staff reported an average of 205 patients presented to the ED per month seeking care for the last six months.

Review of the medical record showed that patient # 16 (MDS) dated [DATE] at 7:58 a.m. with complaints of persistent cough over past 3 weeks and chest pain radiating from her left shoulder down through her left breast. At 8:00 a.m. staff documented patient # 16's blood pressure was elevated at 183/101 (normal range is 120-140 / 80-90), her heart rate was slightly elevated at 92, her respiratory rate was elevated at 22 breaths a minute (normal is 16 at rest), she had 4+ pitting edema in both ankles and she rated her chest pain 8 on a scale of 1-10 (10 being the most severe). Further documentation showed patient # 16 had recently received treatment for bronchitis which included an infusion of ceftriaxone 1 mg (antibiotic) along with an injection of solumedrol (anti-inflammatory) and a breathing treatment on 11/16/17, followed by an injection of Rocephin (antibiotic) on 11/26/17 and again on 11/27/17. Mid-level practitioner G documented patient # 16 complained of left anterior chest pain and had bruising (not further described) on her left side.

At 10:15 a.m. patient # 16 received a dose of Potassium 40 mEq/30 ml, and a dose of Ativan 2mg IV for anxiety at 11:15 a.m.

At 1:05 p.m. a chest CT scan (special type of x-ray) showed that patient # 16 had a small left pleural effusion (fluid around the lung) with underlying basilar atelectasis (collapse of the bottom part of the lung) and that the radiologist discussed the results with mid-level practitioner G at 1:24 p.m. Mid-level practitioner G diagnosed patient # 16 with community-acquired pneumonia and instructed the patient to complete a course of prescribed antibiotics (azithromycin 500 mg for 6 doses), drink plenty of fluids, and to continue present medications including a prescription for potassium 40 meq 2 times a day. Documentation showed the patient left the ED at 2:41 p.m. At the time of discharge the pt's BP was 141/87, HR 75 and respiratory rate 20.

The medical record did not contain evidence that patient # 16 received further examination and treatment to stabilize her emergency medical condition (pneumonia that had not resolved after multiple rounds of outpatient antibiotic therapy) prior to discharge. The patient failed to improve after receiving outpatient antibiotic therapy over three and a half weeks, leading to inpatient hospitalization at another hospital 12 hours after discharge.

INTERVIEWS:

In an interview on 12/19/17 at 4:15 PM registered nurse (RN) A stated that patient # 16 complained that her pain was greater when she coughed. RN A also stated that mid-level practitioner G was going to admit patient # 16 but changed his mind. "We've been having a shortage of intravenous fluids so he decided not to admit her."

In an interview on 12/19/17 at 4:30 PM, mid-level practitioner G stated that patient # 16 had upper respiratory symptoms for several weeks. I had seen her a time or two before. From my perspective she had not been getting the appropriate dosage of antibiotics. The chest x-ray showed pneumonia in the left lower lobe. I mentioned to one of the nurses I thought she would be admitted , they had already moved her to a hospital room before I got the CT scan reading. I talked to physician F and he was fine with discharge. I concluded after reviewing her antibiotics that if we would double up on her Z-pack it would help.

In an interview on 12/20/17 at 9:36 a.m. RN A stated that mid-level practitioner G said he was going to admit patient # 16 for IV antibiotics because she had pneumonia. Once I had the ward clerk admit patient # 16, I went to mid-level practitioner G's office, he changed his mind after talking with the pharmacist and the Director of Nursing and found out we didn't have the IV fluids for the medications he wanted to give. I told patient # 16 that it might be in her best interest to go to a larger hospital that had more testing capabilities, but that we would be happy to see her here.

In an interview on 12/20/17 at 11:15 a.m., the Director of Nursing stated that mid-level practitioner G was thinking about admitting the patient and giving her two IV antibiotics. I told him before he put his orders into the computer to talk to the pharmacist to make sure we had what we needed to take care of the patient. If she needed to be in acute level of care we would have to transfer.

In an interview on 12/19/17 at 4:00 p.m. the Medical Director stated he was called twice about patient # 16, once was because mid-level practitioner G was going to admit her, the second was because he felt she was getting better. "I'm not the one that says yes or no. I am the one that says okay, I go by what they say." If she was receiving outpatient therapy in the past, I would not do another trial of antibiotics, it was most likely viral. He was going to admit her but then he decided not to.

Review of hospital B's medical record showed patient #16 presented to the ED at 2:38 a.m. on 12/5/17, approximately 12 hours after discharge from Keokuk County Health Center for treatment of left lower lobe pneumonia unresponsive to outpatient treatment. Further documentation showed patient # 16 was admitted for treatment to stabilize her emergency medical condition.