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.

Based on record review and staff interview, the hospital failed to provide within its capabilities, stabilizing treatment prior to discharging one patient (#7). The patient presented to the hospital emergency department seeking care for an emergency medical condition out of a sample selected from November 2017 through April 2018.

The hospital had the capacity and capability to stablize the EMC to include further assessment of the patients' signs and symptoms to ensure that the patient was not suffering from a medical emergency.

The ED averaged 44,000 emergency visits per year.

Refer to 2407 for further details.

Based on record review and staff interview, the hospital failed to provide within its capabilities, stabilizing treatment prior to discharging one patient (#7) that presented to the hospital emergency department seeking care for an emergency medical condition (EMC) out of a sample selected from November 2017 through April 2018. The ED averaged 44,000 emergency visits per year.

Findings included:

1. Review of the Hospital's policy titled, "Patient Transfers and Emergency Medical Treatment and Active Labor Act (EMTALA)" revised 08/26/15, showed the directives for staff to appropriate stabilize an EMC:
- Medical screening exam (MSE) refers to the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exist. Such screening must be done within the facility's capability and available personnel, including on-call physicians and other Qualified Medical Personnel (QMP.) The MSE is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either Stabilized or appropriately transferred.
- EMC means and manifests itself by acute symptoms of sufficient severity, (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual in serious jeopardy; serious impairment to bodily functions; and serious dysfunction of any bodily organ or part.
-Stable or Stabilized means with respect to EMC, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility. With respect to individuals ready for discharge, that within reasonable clinical confidence, continued care, including diagnostic work-up and treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions.

Review of Patient #7's ED medical record dated 04/08/18
- On 04/08/18 at 4:55 PM, Patient #7, a [AGE] year old female, arrived at the Hospital, accompanied by Emergency Medical Service (EMS);
- At 4:55 PM, the chief complaint was seizures witnessed at bus stop. The patient was on anti-seizures medication and had a history of seizures but hasn't been taking the medications because she did not think she needed them. EMS states she has been run in about 20 times in the last month;
- At 4:54 PM, the patient's history showed stroke, Chronic Back Pain, Schizophrenia Paranoid, Seizures, and Tardive dyskinesia;
- At 5:21 PM, provider note, documented by Staff D, ED Physician, showed chief complaint of seizures. The patient presented via EMS for a seizure at the bus stop. The patient had a history of seizures, stated she hadn't taken some medications as she didn't think it was helpful. The patient also stated she had seizures about once a year. Though we see her more often, as well as EMS reports frequent visit/calls. The patient was observed in the ED, looked well here, will discharge to follow up with Primary Care Physician (PCP.)
- At 5:15 PM, an anticonvulsant medication was administered by mouth (pill form), and a Basic Metabolic Panel (blood test) was drawn;
- At 6:21 PM, progress note, documented by Staff H, LCSW, showed the discharge goal and plan was mutually agreed upon by the patient, LCSW, RN, and Physician. The LCSW contacted Medicare Logisticare for transfer, however, the patient's transportation benefits had expired. Public bus fare was provided and the patient was to be discharged home when medically stable; and
- At 6:30 PM, ED note, documented by Staff F, RN, showed discharged instructions for seizures and follow up was discussed. The patient walked with a steady gait out of the ED with security to the public bus stop. Bus pass was provided, and the patient was given scrub pants to wear because her pants were wet.

Review of the EMS trip ticket, dated 04/08/18, showed Patient #7 was found slumped over at the bus stop with law enforcement (LE) and Fire Department (ED) at her side. LE stated that bystanders told them the patient had a grand mal seizure (type of seizure that involved a loss of consciousness and violent muscle contractions) while setting on a bench. The patient had no obvious injuries and she became more oriented in route to the hospital. The patient had a history of seizures and was supposed to take anticonvulsant's.

During a telephone interview on 04/19/18 at 12:15 PM, Staff D, ED Physician, stated that:
- He remembered Patient #7 and the events on 04/08/18;
- The patient had a seizure;
- The patient told him she had not been taking her medications for a while;
- The Electronic Medical Record (EMR) that the ED physicians used, had the capability to review past visits, and the history of the patient;
- He did not look at the history of visits for the patient;
- It was the patient's rights not to take her medications;
- With patients that have a history of seizures, and not taking their medications, the regular routine treatment was not to load the patient up with the medication that they were taking to prevent seizures;
- He prescribed an anticonvulsant medication by mouth in hopes that it would prevent her from having another seizure;
- He felt that the patient was safe to discharge without supervision for public transportation;
- He was aware that the patient was brought back on 04/09/18 to the ED; and
- If he knew that was going to happen, he would have looked a little harder at her history.

During a telephone interview on 04/18/18 at 1:50 PM, Staff F, RN, stated that:
- She remembered Patient #7 and the events on 04/08/18;
- The patient had not been taking her medication, and had a seizure;
- The physician was ok for her to be discharged ;
- It was sleeting outside, and the LCSW gave her a bus pass, and
- She gave the patient scrub pants and a warm blanket to go outside in.

During a telephone interview on 04/23/18 at 3:40 PM, Staff H, LCSW, stated that:
- She remembered Patient #7 and the events on 04/08/18;
- She did not assess the patient, she was requested by the nurse to supply the patient with a bus pass;
- She did not know what support system the patient had, and
- She did not check the weather and/or whether the public bus system was running.

Review of the local weather forecast for 04/08/18 through 04/09/18 showed the high was 39 degrees Fahrenheit with a low temperature of 33 degrees Fahrenheit, and occasional rain.

During a telephone interview on 04/19/18 at 11:15 AM, Staff E, PCT, stated that:
- She remembered Patient #7 and the events on 04/08/18;
- She had given the patient scrub pants because her's were wet;
- She walked the patient through the ambulance bay because it was the shortest route to the bus stop,
- She discussed how cold it was with the patient; and
- She did not follow the patient out of the hospital because she did not know what bus stop the patient was supposed to go to.

During a telephone interview on 04/23/18 at 8:20 AM, Staff O, Security, stated that he was asked by the nursing staff to go outside and assist Patient #7, because she was standing out in the rain. When he spoke to the patient, the patient did not know which public bus stop to go to. She wanted to go north so he walked her across the road to the bus stop.

Review of the video surveillance from 04/08/18 through 04/09/18 showed:
- On 04/08/18 at 6:29 PM, Staff E, Patient Care Technician (PCT,) and Patient #7, (identified by the facility), was walking through the Hospital's ambulance bay to a door that Staff E opened and the patient walk through. Staff E did not exit the ambulance bay;
- At 6:30 PM the camera view showed moisture on the lens and the patient was seen standing outside of the hospital with a white blanket draped over her shoulders, and wearing light blue scrub pants;
- There were two public bus stops in view, one on the hospital side, and one across a four lane road. The four lane road connected to the hospital's grounds. The distance from the hospital grounds to the public bus stop across the four lane road was less than 100 feet;
- At 6:36 PM, Staff O, Security, was seen escorting the patient across the four lane road to the bus stop;
- Approximately 10 hours later on 04/09/18 at 4:30 AM, the patient laid down on the sidewalk;
- At 6:07 AM, the camera zoomed in on the patient as she lay on the sidewalk near the road;
- At 6:50 AM, a green truck stopped, turned around, with hazard lights on;
- At 6:54 AM, the bystander from the green truck was seen crossing the road to the hospital's grounds, then returned to the patient where the bystander was seen administering comfort to the patient; and
- At 6:58 AM, EMS arrived and transported the patient to the Hospital's ED.

During an interview on 04/19/18 at 12:05 PM, Staff N, Security Manager, stated that:
- The video surveillance cameras did not zoom in automatically; it had to be done by staff;
- He was told by the dispatcher, who was monitoring the cameras on 04/08/18 at approximately 6:00 AM, a bystander had called the hospita and was concerned about Patient #7. The dispatcher zoomed in on the patient to check on her, and she appeared ok to the dispatcher;
- The dispatcher could have call a rapid response but did not; and
- The dispatcher had no medical training to determine whether or not the patient had an emergency.

During an interview on 04/26/18 at 2:55 PM, Staff M, Security Supervisor, stated that:
- He was working on the night of 04/08/18;
- He received a call from a bystander stating that Patient #7 was at the bus stop and not moving;
- At the same time they got a call for a combative patient;
- He zoomed in with the camera to view Patient #7;
- He did not call a rapid response for Patient #7 because she was off campus; and
- The priority for a rapid response call was based on whether the patient was combative.

Review of the EMS trip ticket, dated 04/09/18, showed the ambulance crew arrived on the scene at 7:00 AM, to find Patient #7 lying on the ground shivering "within feet of the hospital." Documentation showed patient # 7 knew her name and location. The patient had a bruise on her forehead. She was picked up and placed on the cot, then wheeled "10 feet to the hospital."

Medical record review-Patient #7's 03/25/18 (Second Visit, Summary)
On 04/09/18 at 7:12 AM, Patient #7, a [AGE] year old female, arrived at the Hospital, accompanied by EMS. The patient appeared in distress, disheveled, with a contusion to the right forehead, red abrasions on both legs, and did not follow commands. Staff A, Physician noted that the patient was homeless with history of a stroke, a transient ischemic attack (TIA), and seizures. The patient had been seen in the ED on 04/08/18 for seizures. Today, the patient had an altered mental status and was found to have new contusions on her chest and right forehead. She mumbled but was incomprehensible. She opened her eyes and moved her extremities spontaneously but did not follow commands. Her temperature was 82 degrees Fahrenheit (98.6 degrees Fahrenheit, normal body temperature.) The patient was intubated (plastic tube placed in the wind pipe to facilitate breathing,) a warming blanket was applied and she was admitted to the hospital's intensive care unit.

During an interview on 04/18/18 at 1:25 PM, Staff A, ED Medical Director, stated that:
- He was the physician who took care of Patient #7 on 04/09/18;
- The patient was at the bus stop across the street from the hospital;
- She had a core body temperature of 82 degrees Fahrenheit;
- She did not follow commands, and had to be intubated;
- She was admitted to the facility;
- He had spoken with Staff D, and they both agreed that patients have a right not to take their medications;
- With a seizure patient not taking their medications, the regular treatment would not be to load the patient up with their medications to prevent future seizures;
- The ED physicians have the capabilities to review the patient's history through the electronic medical record; and
- It was the hospital's responsibility to respond if a bystander notified staff they were concerned about a patient on hospital property.

During an interview on 04/18/18 at 4:30 PM, Patient #7, stated that:
- She had to buy her own bus ticket;
- She wanted to go back to Facility A but they would not let her come back; and
- She did not get on the bus to return to Facility A because the buses would just pull up and not let her get in, they would just drive off leaving her at the bus stop.

During a telephone interview on 04/23/18 at 1:30 PM, Case Manager (off site) for Patient #7, stated that:
- The patient was unable to take her medication correctly by herself;
- The patient needed someone to help her with her medications;
- When Patient #7 took her medications she was able to function with assistance, if she was off of her medications it was a problem for her medical and psychiatric health;
- On 3/25/18, the patient was a resident at the residential facility A;
- She had eloped from the facility, and ended up in the ED;
- The residential facility A would not accept the patient because she was not taking her medications;
- The homeless shelter had no way of providing medications;
- She was removed by LE from the homeless shelter for psychotic behavior;
- She was placed in another residential facility (residential facility B) where the patient eloped within a few hours;
- The patient had a seizure and was returned to the ED on 04/08/18;
- She was discharge from the ED to bus stop;
- The patient did not have the mental capacity to ride the bus;
- The patient stayed at the bus stop all night where she was found unresponsive with a low body temperature of 82 degrees Farenheit; and
- On 04/09/18 the patient was brought to the ED by EMS.

Documentation in the medical record showed the facility failed to stabilize Patient #7's emergency medical condition prior to discharge. The medical record did not contain evidence to indicate whether or not the patient had the ability to obtain her anti-seizure medications or could navigate safely to her residence. These oversights allowed the patient to leave the facility with an unstabilized emergency. The patient returned to the ED approximately 12 hours after discharge with an emergency condition that required intubation and mechanical ventilation and admission to the hospital's intensive care unit.