HospitalInspections.org

Based on interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA when:

1. The hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) for seven of 24 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 10 and Patient 12). (Refer to A2406)

Because of the avoidable death of Pt 1's unborn baby, serious actual harm to Pt 3 and serious potential harm to Pt 2, Pt 4, Pt 8 and Pt 10 related to having an emergency medical condition and an appropriate Medical Screening Exam (MSE) was not conducted an Immediate Jeopardy (IJ) situation was called for CFR 489.24(a) A2406 on 4/12/2024 at 5:45 p.m. with the Director of Quality (QD) Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Chief Medical Officer (CMO) and Emergency Department Director (EDD) and were provided the IJ template which documented the immediate actions necessary to address the IJ situation. The hospital submitted an acceptable IJ Plan of Removal (Version 5) on 4/18/24 at 9:10 a.m. Education, training, and competencies of staff were validated. The components of the IJ Plan of removal were validated onsite through observations, interviews, and record review. The IJ was removed on 4/18/2024 at 2:45p.m. with the Director of Quality, Chief Executive Officer, Chief Nursing Officer, Chief Medical Officer, Emergency Department Director Manager (EDM 1) and Quality Manager (QM). Following the IJ removal, the facility remained in substantial non-compliance.

2. The hospital failed to ensure an emergency medical condition (EMC) was stabilized prior to discharge for five of 24 Patients (Patient 5, Patient 6, Patient 7, Patient 9 and Patient 11). (Refer A2407)

Because of the serious actual harm to Patient 5 and Patient 6 and the potential serious harm to Patient 7 and all patients in Hospital A who had an Emergency Medical Condition (EMC) and not provided stabilizing measures, an Immediate Jeopardy (IJ) situation was called for CFR 489.24(d) A2407 on 4/12/2024 at 5:45 p.m. with the Director of Quality (QD) Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Chief Medical Officer (CMO) and Emergency Department Director (EDD) and were provided the IJ template which documented the immediate actions necessary to address the IJ situation. The hospital submitted an acceptable IJ Plan of Removal (Version 5) on 4/18/24 at 9:10 a.m. Education, training, and competencies of staff were validated. The components of the IJ Plan of removal were validated onsite through observations, interviews, and record review. The IJ was removed on 4/18/2024 at 2:45p.m. with the Director of Quality, Chief Executive Officer, Chief Nursing Officer, Chief Medical Officer, Emergency Department Director Manager (EDM 1) and Quality Manager (QM). Following the IJ removal, the facility remained in substantial non-compliance.

The cumulative effect of these systemic problems resulted in the hospital's inability to provide the statutory EMTALA requirements and care in a safe setting.

Based on observation, interview, and record review, the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [emc] exists) for seven of 24 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 10 and Patient 12) when:

1. Patient (Pt) 1 came to the Obstetric Emergency Department (OB ED) on 3/14/24 with a chief complaint of uterine contractions at 40 weeks gestation. This was Pt 1's fourth pregnancy and it had been uncomplicated. The OB ED Registered Nurse (QMP) conducted an MSE, which included a cervical exam and fetal monitoring for a period of 42 minutes, and Pt 1 was determined to be in active labor (a known EMC). The OB ED RN failed to analyze the fetal monitor results and recognize the need for intervention, discontinued the fetal monitoring without verifying fetal well-being, transferred Pt 1 out of the OB ED to the labor and delivery unit without contacting Pt 1's physician and did not communicate the fetal heart rate monitoring results to the receiving L&D RN.

These failures resulted in delay of an appropriate MSE for the unborn baby, delay in recognizing an EMC existed for the unborn baby, delay in notifying the physician and directly led to the baby's avoidable death.

2. Pt 4 came to the Obstetric Emergency Department (OB ED) on 11/10/23 at 6:27 p.m. complaining of uterine contractions at term. Pt 4 was registered and then sent to the waiting room without being triaged and was not assessed or placed on a fetal monitor for over two and a half hours.

These failures resulted in a delay in the MSE being performed, and a delay in determining whether or not an emergency medical condition existed for Pt 4 and her unborn baby.

3. Pt 2 was brought to the Emergency Department (ED) on 1/15/24 at 9:40 p.m. by a family member with a chief complaint of suicidal ideation (SI-thinking about or planning suicide), overdosed himself last week and was hitting his head on the floor yesterday (1/14/24). The facility staff failed to document Pt 2 had a MSE or was seen by mental health professional. P 2 was sent to the waiting room to wait once triaged by the RN for one hour with no supervision, was roomed in the blue zone (lowest acuity) and Pt 2 left without being seen after being triaged (two hours and 35 minutes later).

This failure resulted in Pt 2 not receiving an appropriate MSE or an assessment by a Mental Health Professional, and placed Pt 2 in danger of self-harm. The hospital failed to determine whether an emergency medical condition existed for Pt 2 and did not initiate measures to ensure Pt 2's safety.

4. Pt 3 came to the Emergency Department (ED) on 1/6/24 at 11:42 a.m. with a chief complaint of headache times two days and vital signs (VS-clinical measurements, heart rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) on arrival were documented as a pulse of 91 beats per minute (bpm; normal range 60-100 bpm), blood pressure of 165/100 millimeters of mercury (mmHg- normal is less than 120/80 mmHg) and pain 10 out of 10 (0-no pain,1 -3 mild pain 4-6 moderate pain 7-10 severe pain). Pt 3's VS were not reassessed before discharge and Pt 3's pain was not reassessed after pain medication administration.

These failures resulted in Pt 3 being discharged to an unknown location without stabilization and experiencing worsening blood pressure. Pt 3 returned to the ED on 1/6/24 at 7:03 p.m. and was later transferred to a higher level of care with a diagnosis of hydrocephalus (the buildup of fluid in cavities called ventricles deep within the brain).

5. Pt 8 was brought in by ambulance (BIBA) to the Emergency Department (ED) on 2/23/24 at 9:58 a.m. for chief complaint of chest pain. Emergency Medical Services (EMS) indicated Pt 8 had taken two Nitroglycerin medications without relief of symptoms and documented low blood pressure. Upon arrival to the ED, Pt 8 was triaged as an ESI of 2, and EKG and cardiac monitor were not performed within the timeframe for chest pain guidelines.

These failures led to a delay of 31 minutes for the EKG to be performed, delay of 41 minutes to provide cardiac monitor support and delayed services and measures meant to stabilize Pt 8's emergency medical condition (EMC).

6. Patient (Pt) 10 was brought into emergency department by ambulance with chief complaint of chest pain. Pt 10 did not have EKG done within 10 minutes of arrival and did not have pain reassessed in accordance with facility policy.

These failures had the potential to result in a delay in identifying the emergency medical condition, delayed medications, treatment, and transfer of Pt 10 to higher level of care.

7. Pt 12 arrived in the Emergency Department (ED) on 4/13/24 at 8:50 p.m. with the chief complaint of "Chest Pain". Pt 12 did not have pain assessed and vitals completed in accordance with the facility policy.

This failure had the potential to result in delay in identifying emergency medical condition and patient being discharged without vitals being stable and pain at an acceptable level.

Because of the avoidable death of Pt 1's unborn baby, serious actual harm to Pt 3 and serious potential harm to Pt 2, Pt 4, Pt 8 and Pt 10 related to having an emergency medical condition and an appropriate Medical Screening Exam (MSE) was not conducted an Immediate Jeopardy (IJ) situation was called for CFR 489.24(a) A2406 on 4/12/2024 at 5:45 p.m. with the Director of Quality (QD) Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Chief Medical Officer (CMO) and Emergency Department Director (EDD) and were provided the IJ template which documented the immediate actions necessary to address the IJ situation. The hospital submitted an acceptable IJ Plan of Removal (Version 5) on 4/18/24 at 9:10 a.m. Education, training, and competencies of staff were validated. The components of the IJ Plan of removal were validated onsite through observations, interviews, and record review. The IJ was removed on 4/18/2024 at 2:45p.m. with the Director of Quality, Chief Executive Officer, Chief Nursing Officer, Chief Medical Officer, Emergency Department Director Manager (EDM 1) and Quality Manager (QM). Following the IJ removal, the facility remained in substantial non-compliance.

Findings:

1.During an interview on 3/28/24 at 3:42 p.m. with Patient (Pt) 1, Pt 1 stated she did not have any complications during her pregnancy. Pt 1 stated her last appointment with her obstetrician was on 3/12/24, which was her due date. Pt 1 stated she was dilated to 3 centimeters (meaning her cervix was dilated; cm- indicates a unit of measurement where 10 cm is fully dilated and ready to give birth). Pt 1 stated she had a non-stress test (NST) scheduled for 3/15/24 but ended up going into labor on 3/14/24. Pt 1 stated she went to the hospital when the contractions got stronger and arrived at approximately 4:30 p.m. Pt 1 stated she went to the fourth floor OB triage (same as OB ED) where she was registered and had her vital signs taken. Pt 1 stated the nurse tried to get the baby's heartbeat, but was not able to. Pt 1 stated she was taken to the OB triage room to a bed where they hooked her up to the fetal monitor and she could hear the baby's heartbeat. Pt 1 stated the nurse told her the heart rate was 133 (beats per minute [bpm]). Pt 1 stated she stayed in the triage bed while she waited for a bed in labor and delivery. Pt 1 stated the fetal monitor was disconnected before she was transported to the sixth floor labor and delivery unit. Pt 1 stated when she got to the labor room she requested an epidural, but was told the anesthesiologist was with another patient so Pt 1 went to the restroom and then walked back to bed. Pt 1 stated the nurse had her sit on the edge of the bed to wait for the anesthesiologist and the nurse did not put the fetal monitor on. Pt 1 stated the nurse could not put the monitor on her because her back was arched, so the nurse was in front of her holding the monitor on her abdomen. Pt 1 said she signed the consent, the anesthesiologist put in the epidural and then they laid her back down on the bed and put the fetal monitor on her but could not find the heartbeat. Pt 1 said they brought in a doppler and still could not find it. Pt 1stated the doctor (MD 4) came in and used an ultrasound machine and said there was no heartbeat and no movement. Pt 1 stated a lady put her hands on Pt 1's stomach and "shook it to get him [the baby] moving," and another nurse asked about going to the operating room for a c-section. Pt 1 stated the doctor (MD 4) "decided no c-section, let's let it come naturally." Pt 1 stated her baby had a heartbeat when she was in triage and questioned why they couldn't have resuscitated him. Pt 1 stated "they wrote the time of death at 6 p.m. and I asked if they were 100% positive. They said yes, he was gone, and they were going to confirm with another ultrasound. I'm thinking why wait so many hours after to do an ultrasound, why not do a c-section?"

During a concurrent interview and record review on 4/9/24 at 3:20 p.m. with Obstetric Emergency Department (OB ED) Registered Nurse (RN 10), Pt 1's medical record was reviewed. The record indicated Pt 1 was 40 weeks and two days pregnant with her fourth baby. Review of the "Labor and Delivery [L&D] Timeline" indicated Pt 1 came to the OB ED on 3/14/24 at 4:38 p.m. with a chief complaint of contractions which started at 3 a.m. that morning. Pt 1 was moved from the waiting room to a bed in the OB ED at 4:45 p.m. The L&D Timeline indicated at 5 p.m., an external fetal monitor was in place and the fetal heart rate (FHR) was 140 beats per minute (bpm). There was no assessment of the unborn baby's FHR variability, presence, or absence of accelerations and/or decelerations, or characteristics of uterine contractions. Pt 1's pain level was 7/10 (meaning on a scale of 1 to 10, pain level was 7, or moderate to severe pain). At 5:02 p.m., a cervical exam indicated Pt 1 was dilated to 6 cm, intact membranes, 70% effaced (effacement- thinning and shortening of the cervix), and the presenting part was at a minus 2 station (The location of the baby's presenting part [head] is in relationship to the ischial spines of the pelvis). At 5:05 p.m., admission orders were entered into the electronic health record (EHR) by RN 1 as "Telephone orders with readback [when the physician gives orders over the phone to the RN, and the RN reads those orders back to the physician to confirm accuracy]." The orders included intravenous (IV) fluid, lab tests, medications for pain and an order for an epidural. At 6:54 p.m., RN 1 documented a provider notification note for 5:09 p.m. which indicated "Provider in [Operating Room] OR, RN to enter orders." RN 10 stated there is no documentation in the record indicating RN 1 spoke with the obstetrician (MD 4), or attempted to contact MD 4. RN 10 stated if an RN needed to communicate with a physician who was in the OR, a call could be made into the OR to directly speak with the physician, or to a nurse in the OR. The L&D timeline indicated an IV was placed and a 1000 milliliter (ml) fluid bolus was started. At 5:20 p.m., RN 1's note indicated Pt 1 was having contractions every 1-5 minutes lasting 60-90 seconds, the FHR was 140 bpm, with absent accelerations and minimal variability. RN 1's note also indicated Pt 1 requested an epidural and that this request was communicated by RN 1 to the Practice Coordinator (PC 1) in L&D. The timeline indicated at 5:28 p.m., Pt 1's pain level was 7/10 with Pt 1's pain goal 6/10. At 5:42 p.m., RN 1's note indicated the FHR was 145 bpm, minimal variability, absent accelerations, and variable decelerations. Fetal monitoring was discontinued at 5:42 p.m. There was no indication that RN 1 attempted to notify MD 4 of the minimal FHR variability or absent accelerations for the 42 minutes of fetal monitoring, or the variable deceleration.

During a concurrent interview and record review on 4/9/24 at 3:55 p.m. with OB ED RN (RN 10), Pt 1's medical record was reviewed. Review of the L&D timeline indicated Pt 1 was transferred from the OB ED on the fourth floor to labor and delivery on the sixth floor at 6:04 p.m., with report given by RN 1 to L&D RN (RN 2). RN 10 stated there is nothing else documented from 5:42 p.m. until 6:09 p.m. when vital signs were obtained, and no documentation of fetal status after 5:42 p.m. The record indicated a consent form for anesthesia was signed by Pt 1 at 6:10 p.m. and review of the anesthesiologist (MD 5) notes indicated at 6:23 p.m. an epidural catheter was placed and at 6:25 p.m. the epidural medication was started. MD 5's note indicated Pt 1's vital signs and FHR were monitored throughout the procedure and remained unchanged. The fetal monitor strips beginning at 6:04 p.m. did not reflect a baseline fetal heart rate. RN 10 stated there was no documentation of an assessment of the FHR after 5:42 p.m., and no assessment by the obstetrician (MD 4) prior to placement of the epidural. RN 10 stated there are times a patient does get an epidural before being seen by an obstetrician if orders for the epidural are obtained by the RN through a telephone order. Review of RN 2's notes indicated at 6:25 p.m. RN 2 repositioned Pt 1 following epidural placement and attempted unsuccessfully to obtain a FHR. The OB ED on-call physician (MD 4) was notified and was at Pt 1's bedside at 6:36 p.m.. MD 4 performed a bedside ultrasound and confirmed there was no FHR. Review of MD 4's OB history and Physical dated 3/14/24 at 6:59 p.m. indicated, "...I was called to the bedside in my role as the OB ED Laborist to assess an urgent issue, the inability to find fetal heart tones. This was the first time I was notified that the patient was admitted for active labor..." A review of MD 4's OB Vaginal Delivery Note dated 3/15/24 at 12:01 a.m., indicated Pt 1 had delivered a stillborn male infant at 11:33 p.m. on 3/14/24 with a "tight nuchal cord that could not be reduced...There was a large 6 inch clot noted in the cord at the fetal insertion...Intact placenta delivered on 3/14/24 at 11 :36 p.m. Membranes were meconium stained..."

During a review of the fetal monitor strip dated 3/14/24 beginning at 5 p.m. and ending at 5:42 p.m., the monitor strip indicated a baseline fetal heart rate of 140-145 bpm, minimal FHR variability, and no FHR accelerations. At 5:36 p.m., the monitor strip indicated a variable deceleration. There were also several instances where the heart rate did not record, at 5:05 p.m. for less than one minute, at 5:09 p.m. for approximately two minutes, at 5:23 p.m. for less than one minute and at 5:29 p.m. for approximately two minutes. The monitor strip stops at 5:42 p.m. and 50 seconds and does not resume until 6:04 p.m. A review of the fetal monitor strip dated 3/14/24 beginning at 6:04 p.m. and ending at approximately 6:16 p.m., indicated between 6:04 p.m. and 6:08 p.m. a baseline FHR could not be determined, and from 6:08 p.m. until 6:16 p.m. there is sporadic recording of a heart rate of 100-110 bpm and there are no corresponding nurses notes to provide an explanation for what is reflected on the monitor strip, and no indication in the record that the maternal pulse was assessed at the same time as the fetal heart rate in order to ensure the fetal heart beat was correctly identified.

During an interview on 4/11/24 at 3 p.m. with registered nurse (RN) 1, RN 1 stated she was the OB ED nurse who took care of Pt 1 on 3/14/24. RN 1 stated she did not notify MD 4 that Pt 1 was at the hospital in labor, did not leave a message for MD 4, and did not notify MD 4 regarding the FHR tracing being a category II tracing. RN 1 stated she knew that MD 4 was in the operating room (OR) with a patient and RN 1 stated she did not want to disturb MD 4. RN 1 stated she was aware that if MD 4 was in the OR, she could have called into the OR, called MD 4's phone and left a message or contacted the PC to go into the OR to speak with MD 4 if she needed to reach her. RN 1 stated instead of doing any of those things, she put orders in for Pt 1 with the intention of contacting MD 4 later. RN 1 stated when the orders were put in, she selected "telephone with readback," and understands this was not accurate, she did not speak with MD 4 or receive orders from MD 4. RN 1 stated she and another RN moved Pt 1 in the bed down to the elevators. RN 2 met them there and RN 1 and RN 2 both accompanied Pt 1 to a labor and delivery room. RN 1 stated she gave a brief report to RN 2, but did not give a report about the baby's fetal heart rate tracing. RN 1 stated she should have communicated this to RN 2, and that it was "inappropriate" for her (RN 1) not to have done so. RN 1 stated she did not inform RN 2 or the PC (PC 1) that she had not spoken with MD 4, or that she did not receive telephone orders for admission or for an epidural from MD 4 as she (RN 1) had indicated in the medical record.

During an interview on 4/11/24 at 4:25 p.m. with RN 2, RN 2 stated she was the labor and delivery nurse who received Pt 1 from OB ED on 3/14/24. RN 2 stated she was asked by PC 1 if she could take Pt 1 who was being admitted in active labor from OB ED, and although RN 2 already had a patient, she was in early labor, so RN 2 agreed to take Pt 1. RN 2 stated PC 1 told her Pt 1 was going to have an epidural. RN 2 stated she met RN 1 and Pt 1 at the elevator and received report from RN 1. RN 2 stated she was provided a brief report about Pt 1 and was told Pt 1 wanted an epidural. RN 2 stated she did not receive report regarding the status of the baby including the FHR tracing. RN 2 stated she would have expected to be informed if there were any concerns about the baby. RN 2 stated she assumed RN 1 notified the physician and obtained orders from the physician. RN 2 stated the anesthesiologist was getting set up when Pt 1 arrived in L&D. Pt 1 went to the bathroom and came back and sat on the side of the bed for the epidural procedure. RN 2 stated she was positioned at bedside down in front of Pt 1 and held the ultrasound from the fetal monitor up against Pt 1's abdomen in an attempt to obtain the fetal heart rate while the epidural was being placed. RN 2 stated she did not look at the fetal monitor during the epidural while she held the ultrasound on pt 1's abdomen and thought at the time she was hearing the fetal heartbeat. RN 2 stated after the epidural was in she repositioned Pt 1 lying down and then attempted to obtain the FHR but did not detect a heartbeat. RN 2 stated she did Leopold's maneuvers (abdominal palpation used to determine fetal presentation) but did not feel any fetal movement. RN 2 stated she called for assistance and MD 4 was called to the bedside. RN 2 stated MD 4 performed an ultrasound and did not detect a heartbeat.

During an interview on 4/16/24 at 10:35 a.m. with the Chief Medical Officer (CMO), the CMO stated in a hospital with in-house obstetrician coverage twenty-four hours a day and the capability for fetal monitoring twenty-four hours a day, an intrapartum fetal death should not occur.

During an interview on 4/16/24 at 1:40 p.m. with PC 1, PC 1 stated she was the PC on the day shift in L&D on 3/14/24. PC 1 stated she was notified that Pt 1 was in the OB ED, was in active labor and needed a bed. PC 1 stated she was also contacted by RN 1 to notify her that Pt 1 had requested an epidural, so PC 1 could let the anesthesiologist in L&D know for planning purposes. PC 1 stated that was the extent of the information she was given about Pt 1 and did not know the fetal monitor strip in OB ED indicated a Category II tracing. PC 1 stated she was called after RN 2 could not find a FHR after the epidural was placed. PC 1 stated she did not find out until after the dayshift ended at 7:30 p.m. that RN 1 did not call MD 4 to notify her of Pt 1's arrival, contractions, cervical exam and results of fetal monitoring, and did not obtain telephone orders from MD 4 for admission and an epidural. PC 1 stated if she was asked for help contacting a physician who was in the OR, she would have done that. PC 1 stated she expected the RN in OB ED to provide report to the L&D RN regarding the well-being of the patient and the baby including a review of the fetal monitor strip, and to have notified the physician and obtained orders for admission and labor prior to transferring the patient to L&D. PC 1 stated fetal well-being should be determined prior to a labor epidural being placed.

During an interview on 4/16/24 at 3:20 p.m. with the OB director (OBD), the OBD stated it is her expectation that RN to RN report at transfer includes a review of the fetal monitor strips. The OBD stated an RN should never indicate an order was obtained from a physician by telephone unless it was. The OBD stated MD 4 should have been notified of Pt 1, including the results of the fetal monitoring while she was in the OB ED. The OBD stated fetal well-being should be established prior to the patient receiving an epidural.

During a review of the State of California Certificate of Fetal Death issued on 4/8/24, the certificate indicated, "...THIS FETUS- DATE OF EVENT [Fetal Death]: 3/14/2024 HOUR: 1800 [6 p.m.] ..." The Certificate of Fetal Death was signed by MD 4 on 4/2/24.

During a review of the policy and procedure (P&P) titled, "STANDARDIZED PROCEDURE: OB MEDICAL SCREENING EXAMINATION," dated 1/22, the P&P indicated, "...Initiate a Medical Screening Examination (MSE) on pregnant patients of 20 weeks gestation or greater to determine if an Emergency Medical Condition (EMC) related to the pregnancy exists...Notify the physician immediately for any of the following conditions:...Category 2 or 3 Fetal Tracing... All patients will be assessed for: Contractions: resting tone, frequency, duration, and intensity of contractions; Fetal heart rate: baseline, accelerations, decelerations, variability (minimum of a 20-minute strip); Vaginal exam unless contraindicated. Communicate all assessment findings to the physician. Obtain further orders from the doctor i.e. (admit/discharge, or any further testing) ..."

During a review of the P&P titled, Scope of Services for the Obstetrical Emergency Department," dated 4/20, the P&P indicated, "...Patients in labor will be transferred to the L&D unit after an appropriate medical screening examination [MSE] and stabilization in accordance with EMTALA regulations unless presenting with an emergent situation..."

During a review of the [Name of Hospital] website accessed 4/12/24 at 6:46 p.m., the website indicated, "As part of our vision to elevate the level of care and service we provide to expectant moms, [Name of hospital] is proud to provide the Central Valley area's only OB Emergency Department (OBED) that is staffed 24/7, 365 days a year, with Board Certified OB/GYN hospitalists. If you are greater than 20 weeks and have an urgent or emergent pregnancy-related need, take comfort in knowing that you will be seen by one of our OB/GYN hospitalists or your personal OB/GYN - regardless of time, complications, or circumstances."

During a review of the P&P titled, "Care of the Obstetrical Emergency Department [OB ED] Patient," dated 6/20, the P&P indicated, "...Patients that are 20 weeks gestation or greater that present to the OB ED with obstetrical complaints other than scheduled Inductions/Cesarean sections, may be assessed and observed for no more than four (4) hours in the OB ED...A qualified Obstetrical triage nurse will briefly and accurately evaluate all patients based upon urgency of complaints or time of arrival if equal urgency, including but not limited to chief complaint and clinical status, using the Maternal Fetal Triage Index (MFTI a 5-level system to facilitate the care of pregnant women seeking care in an obstetrical triage unit [priority 1 being the highest acuity and priority 5 being the lowest acuity])...After triage assessment, patients who do not require immediate care shall be assigned to an exam room as soon as possible...Continuous fetal monitoring will be initiated as applicable for pregnancy gestations 24 weeks or greater, and a Non-Stress Test [NST] conducted to evaluate fetal heart rate, variability, presence of periodic and/or episodic patterns, fetal movement and presence of contractions...A complete nursing assessment shall include, but is not limited to maternal physical status, fetal status, labor status, psychosocial needs and patient interview...The primary Physician/On-call Physician/Hospitalist shall be notified after the initial assessment is complete..."

During a review of the P&P titled, Scope of Services for the Obstetrical Emergency Department," dated 4/20, the P&P indicated, "...The OB ED is open for service to Obstetrical patients, physicians and staff twenty-four (24) hours a day, seven (7) days a week. Then OB ED delivers care to pregnant patients of all ages, 20 weeks gestation or greater, who are experiencing uncomplicated emergency and/or remedial problems associated with pregnancy...The [Name of Hospital] OB ED shall fulfill the following responsibilities: a. Assessment, evaluation, management, and treatment, that is appropriate and timely to patients with obstetric conditions. b. Definitive care for those patients not requiring greater in-depth expertise or follow-up care. c. Provision of care that begins in the prehospital setting (provided by EMS), continues in the OB ED, and concludes with responsibility for the patient transferred to the Labor and Delivery [L&D] Unit, another unit, to another physician, or the patient is discharged...The Obstetrical Unit of ED will be covered by Board Certified OB/GYNs to include private physicians and OB Hospitalist program. The Hospitalist group will remain in hospital 24/7 to provide emergency coverage and provide medical care to the uninsured, no established prenatal care patients...Patients are triaged upon arrival, they are seen on the basis of acuity, otherwise they are treated on a first-come, first-served basis...All patients entering the OB ED
shall be assessed by an RN...Patients will be classified according to the Maternal Fetal Triage Index..."

During a review of the policy and procedure (P&P) titled, Epidural Anesthesia For Labor Patients, Patient Controlled," dated 12/21, the P&P indicated,"...PURPOSE: To provide guidelines to nursing staff in assisting the anesthesiologist with epidurals for Labor and Delivery, considering care for mother and unborn fetus. POLICY: Continuous epidural anesthesia is administered by a qualified provider as described by the American Society of Anesthesiologists...Candidates for epidural anesthesia will be agreed upon by the anesthesiologist and the obstetrician. PROCEDURE: Pre-Procedure by RN: Apply Fetal Monitor and assess the FHR. Notify the obstetrician and obtain an order of patient request for epidural anesthesia. Notify anesthesiologist assigned to labor and delivery...Assess the fetal heart rate as continuous as possible during the procedure...Monitor fetal heart rate and contractions continuously during epidural infusion..."

During a review of the policy and procedure (P&P) titled, "Fetal Heart Rate And Uterine Surveillance," dated 8/23, the P&P indicated, "... Procedure for External EFM Ultrasound Application- Validate the fetal heart rate by auscultation before placing the transducer. Assess and confirm FHR baseline rate, baseline variability, and FHR pattern characteristics [presence or absence of accelerations and/or decelerations], and interventions as appropriate using the NICHD definitions. Differentiate fetal heart tracing with maternal heart rate upon admission and as clinically indicated. This can be done by checking the mother's pulse, or briefly with the pulse oximeter.... Include in RN and OB Provider shift handoff communications: Admission FHR and uterine pattern, Current FHR and uterine pattern, and Significant events and interventions in labor..."

During a review of the policy and procedure (P&P) titled, "Fetal Heart Rate And Uterine Surveillance," dated 8/23, the P&P indicated, "...All patients presenting to Labor and Delivery units at viability should undergo an initial period of electronic fetal monitoring for a minimum of 20 minutes or until fetal well-being is assured after the MFTI (maternal fetal triage index) is assigned. Monitoring for longer periods may be continued depending on the clinical circumstances... Documentation regarding assessment of FHR pattern and uterine activity: Use the full description of the FHR tracing per NICHD definitions to include FHR baseline rate, baseline variability, and FHR pattern characteristics (presence or absence of accelerations and/or type of decelerations), and interventions as appropriate. Document the actions taken to maintain a continuous FHR tracing and/or uterine activity tracing.

During a review of the policy and procedure (P&P) titled, "Fetal Heart Rate And Uterine Surveillance," dated 8/23, the P&P indicated, "..Manage the FHR patterns based upon the interpretation of the tracing ... Management algorithm for intrapartum fetal heart rate [FHR] tracing. Category II-evaluation and surveillance. Absent FHR accelerations and Absent/Minimal FHR variability- Initiate intrauterine resuscitation as appropriate for Category II patterns and document interventions...Documentation regarding Indeterminate (Category II) / Abnormal (Category III) FHR Patterns includes duration of the indeterminate/abnormal FHR pattern, clinical context (e.g. tachysystole, maternal hypotension, maternal temperature, bleeding, medications, etc.), specific intrauterine resuscitation measures implemented and the maternal- fetal response, and notification of the OB Provider and the content of the conversation. Examples of Category II FHR tracings include any of the following:...Minimal baseline variability [Minimal variability- Amplitude range is greater than undetectable and less than or equal to 5 bpm] ..."

During a review of the policy and procedure (P&P) titled, "Orders Management," dated 1/2020, the P&P indicated, "...Telephone /Verbal Orders are accepted in limited situations: A. Communication of orders by this method is limited to urgent situations where immediate written or electronic communication is not feasible. B. The appropriate communication type (Telephone or Verbal) is selected. C. The entire order is entered and then read back and confirmed to the ordering Licensed Independent Practitioner [LIP]..."

During a review of the professional reference titled, "American College of Obstetricians and Gynecologists Committee Opinion Number 667, Hospital-based Triage of Obstetric Patients," dated 7/2016 (reaffirmed 2020), the reference indicated, "...An individual or individuals determined qualified as designated by hospital policy must perform an appropriate medical screening examination to determine whether the patient has an emergency medical condition. This determination should take into account the health of the woman and the fetus..."

During a review of the professional reference titled, "American Society of Anesthesiologists Statement on Neuraxial Analgesia or Anesthesia in Obstetrics," dated 10/13/21, the reference indicated, "...Neuraxial analgesia or anesthesia should not be administered until: 1) the patient has been examined by a qualified individual; and 2) a physician with obstetrical privileges to perform operative vaginal or cesarean delivery, who has knowledge of the maternal and fetal status and the progress of labor and who agrees with the initiation of labor analgesia, is readily available to supervise the labor and manage any obstetric complications that may arise. Under circumstances defined by department protocol, qualified personnel may perform the initial pelvic examination. The physician responsible for the patient's obstetrical care should be informed of her status so that a decision can be made regarding present risk and further management. Neuraxial analgesia for labor and/or vaginal delivery requires that the parturient' s vital signs and the fetal heart rate be monitored and documented by a qualified individual..."

During a review of the professional reference titled, "Practice Guidelines for Obstetric Anesthesia An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology," dated 2/2016, the reference indicated, "... Conduct a focused history and physical examination

Based on interview and record review, the hospital failed to ensure an emergency medical condition was stabilized prior to discharge for five of 24 Patients (Patient 5, Patient 6, Patient 7, Patient 9 and Patient 11) when:

1. Pt 5 came to the emergency department (ED) by ambulance on 4/1/24 with a chief complaint of shortness of breath and had missed the prior two dialysis (removal of was and fluid from the body when the kidneys do not work) treatments. Pt 5 did not receive dialysis in the ED and was discharged without any outpatient follow up for dialysis treatment.

These failures resulted in Pt 5 experiencing worsening shortness of breath, experiencing hypoxia (a state in which oxygen is not available in adequate amount at the tissue level) and tachypnea (unusal fast breathing) and the need to return to the ED on 4/2/24 at 9:35 a.m. (6 hours and 18 minutes later).

2. Patient (Pt) 6 came to the ED at 9:30 p.m. on 4/4/24 with a chief complaint of "[Shortness of breath] and throat pain". Pt 6 was not able to swallow his antibiotics due to swelling secondary to peritonsillar abscess (pocket of pus in that collects when tissue becomes infected) and was not assessed for pain prior to discharge. Pt 6 had no primary care physician and was not given follow up instruction for outpatient resources and clinics in accordance with facility's process.

These failures resulted in Pt 6 experiencing worsening pain, worsening difficulty in swallowing, difficulty in managing secretions and returned to Emergency Department (ED) three times before requiring inpatient services.

3. Pt 7 came to the Emergency Department (ED) on 3/28/24 at 8:48 a.m. with a chief complaint of hyperglycemia (high blood sugar) and abdominal pain, excessive thirst, frequent urination, and abdominal pain. Pt 7 received insulin (medication for diabetes) for the first time and was discharged without a blood sugar check prior to discharge.

These failures resulted in Pt 7 being discharged without stable blood sugar level. Pt 7 returned to the ED 30 hours and 54 minutes later with blurred vision, increase heart rate and increased blood pressure requiring inpatient admission for diabetic ketoacidosis (DKA-serious complication of diabetes).

4. Pt 11 came to the emergency department (ED) on 4/17/24 with a chief complaint of hyperglycemia (high blood sugar). Pt 11 was sent to ED by the primary care physician (PCP) due to a high blood sugar. Pt 11's blood sugar on arrival to ED was 351. Pt 11 received fluids and was discharged home without having blood sugar rechecked prior to discharge. Pt 11 was instructed to follow up and care was not arranged prior to discharge.

These failures had the potential to result in Pt 11 experiencing worsening hyperglycemia and being discharged with unstable blood glucose.

5. Pt 9 came to the ED on 1/9/24 at 4:31 p.m. with a chief complaint of shortness of breath (SOB) and chest pain for four days. Pt 9 did not have an EKG read by the physician within ten minutes of arrival. Pt 9 was initially given an ESI level of 3 and should have been a 2. Pt 9 had a troponin (indicates heart muscle damage or a heart attack) lab draw on 1/9/24 and did not have a repeat troponin level measured. Pt 9's vital signs were not reassessed every two hours and did not have stable vital signs before discharge.

These failures resulted in Pt 9 having a delay in a MSE and being discharged home without stabilizing an emergency medical condition. Pt 9 returned to the ED on 1/11/24 at 12:50 p.m. and was later admitted to the hospital for an elevated troponin level (a protein that is released into the bloodstream during a heart attack), a thoracentesis procedure (a procedure to remove fluid or air from around the lungs) and continued peritoneal dialysis (PD-a type of dialysis treatment for kidney failure) in the hospital.

Because of the serious actual harm to Patient 5 and Patient 6 and the potential serious harm to Patient 7 and all patients in Hospital A who have an EMC and are not provided appropriate stabilizating measures, an Immediate Jeopardy (IJ) situation was called for CFR 489.24(d), A2407 on 4/12/2024 at 5:45 p.m. with the Director of Quality (QD) Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Chief Medical Officer (CMO) and Emergency Department Director (EDD) and were provided the IJ template which documented the immediate actions necessary to address the IJ situation. The hospital submitted an acceptable IJ Plan of Removal (Version 5) on 4/18/24 at 9:10 a.m. Education, training, and competencies of staff were validated. The components of the IJ Plan of removal were validated onsite through observations, interviews, and record review. The IJ was removed on 4/18/2024 at 2:45p.m. with the Director of Quality, Chief Executive Officer, Chief Nursing Officer, Chief Medical Officer, Emergency Department Director Manager (EDM 1) and Quality Manager (QM). Following the IJ removal, the facility remained in substantial non-compliance.

Findings:

1.During a concurrent interview and record review on 4/11/24 at 10:00 a.m. with the Director of Emergency Department (EDD), Patient (Pt) 5's medical record was reviewed. The document titled "Emergency Department (ED) care timeline" and "ED physician note" for the ED Visit dated 4/1/24 indicated, on 4/1/24 at 6:25 p.m. Pt 5 was brought into the facility's ED by Emergency Medical Services (EMS). Pt 5 had a past medical history of Congestive Heart Failure (CHF- weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), chronic kidney disease (CKD - condition in which the kidneys are damaged and cannot filter blood), on hemodialysis (treatment to filter wastes and water from blood as kidneys do) Monday, Wednesday, and Friday with bilateral below the knee amputation (BKA). Pt 5 missed the prior two hemodialysis treatments before ED arrival on 4/1/24. EMS found Pt 5's oxygen saturation (vital parameter to define blood oxygen content and oxygen delivery, for adults, the normal range of oxygen saturation is 95 - 100%) at 70% on 5 liters per minute (lpm - unit of measurement) of oxygen. EMS started Pt 5 on non-rebreather mask (a special medical device that helps provide you with oxygen in emergencies) at 15 lpm of oxygen and Pt 5 was brought into ED on 4/1/24 at 6:25 p.m. Pt 5 was triaged at 6:34 p.m. and Emergency Severity Index (ESI - Scoring system used in ED to triage patient to assesses acuity on presentation to the emergency department from most urgent (1) to least urgent (5)) of 1 was assigned. Pt 5 was evaluated by first provider at 6:32 p.m. Pt 5 had a full nursing assessment done at 6: 40 p.m. Orders were placed for Point of care testing (POCT- clinical laboratory testing conducted close to the site of patient care where care or treatment is provided) for electrolyte, lactate (marker of less oxygen to tissue and indicates presence of poor blood flow through the tissue) and venous blood gas (test to determine carbon dioxide and acidity of the blood), comprehensive metabolic panel (CMP- a routine blood test that measures 14 different substances in a sample of blood, to check the body's fluid balance and levels of essential minerals that are vital to key functions in the body), complete blood count (CBC- blood test that measures many different parts often used to help screen overall health and measures the number of types of blood cells) at 6:40 p.m. Results at 6:46 p.m. for POCT lactate: 2.16 [millimoles per liter - scientific unit often used to measure chemicals](normal range:0.5-2), results at 7:08 p.m. for CMP: ...Blood Urea Nitrogen (BUN- amount of urea nitrogen found in blood): 43 mg/dL (Milligrams per deciliter - Unit of measurement) (normal range: 8-21) ... Creatine (measure of how well kidneys are performing their job of filtering waste from blood): 9:04 mg/dL (normal range: 0.50-1.20). Results at 7:22 p.m. for Troponin: 78 ng/l (Nanograms per liter -Unit of measurement) (normal range :0-14). Chest X-ray was completed at 7:23 p.m. and results by radiologist indicate "Correlate for bilateral mid and lower lung fields [infection of lungs with fluids in airways] and [collapse of lung or part of lung]. Asymmetric small volume bilateral [build up of fluid between the tissues that line lungs and the chest] with associated [lung collapse] and consolidations, more on right compared to left." ED physician note indicated, " ...this in the setting of missing her [Pt 5] dialysis for 2 days in a row. States she [Pt 5] has no transportation which is why she keeps missing her dialysis and is unable to ambulate due to BKA ...normally on home oxygen at 5 [lpm] at baseline. On examination she has mild crackles but without significant respiratory distress. [Pt 5] was weaned off of her nonrebreather ...tolerating baseline nasal cannula ... [Pt 5] labs all today are chronic findings ...appropriate for discharge with recommended plan to have dialysis scheduled for this morning ...". ED nursing note, dated 4/2/24 at 2:21 a.m. indicated, " ...Pt expressed that it is getting late and that her caregiver is only there with her during the day, and she lives home by herself at night ..." The document titled "After visit summary (AVS)", dated 4/1/24 indicated , " ...instructions ... you are feeling short of breath because you need to get your dialysis ...Make an appointment to get your dialysis as soon as possible ...you currently have no upcoming appointment scheduled ...you have not been prescribed any medication ..." Pt 5 was discharged on 4/2/24 at 3:09 a.m. (8 hours and 44 minutes later) and sent home via non-emergency transport.

During an interview on 4/11/24 at 10:10 a.m. with the EDD, the EDD stated Pt 5's medical record indicated Pt 5 did not have a primary care physician listed. The EDD stated Pt 5's medical record indicated her care giver was only there during the day and Pt 5 lives by herself . The EDD stated the patient did not receive any dialysis treatment in the ED and record does not indicate any follow up appointment was scheduled for the patient prior to discharge on 4/2/24 at 3:09 a.m. The EDD stated Pt 5' with history of BKA, and not having help at night and transportation concerns to hemodialysis she should not have been discharged at 3:09 a.m. The EDD stated in this situation a consult by a nephrologist (medical doctor who specializes in kidney care & diseases) would have been beneficial to the patient. The EDD stated ED has two spaces available to perform dialysis. The EDD stated dialysis would had helped patient with her shortness of breath. The EDD stated Pt 5's medical record indicated she was not seen by social worker or case manager. The EDD stated adherence to hemodialysis schedule is important to prevent shortness of breath in patient with kidney disease on hemodialysis. The EDD stated the ED team should ensure a patient on hemodialysis should have appropriate resources aligned prior to discharge.

During an interview on 4/11/24 at 2:00 p.m. with the MDED, the MDED stated he was the medical director for the ED. The MDED stated he has reviewed Pt 5's medical record. The MDED stated "Pt 5 would have benefitted from Nephologist consult prior to discharge and potentially would have benefitted from the dialysis in ED." MDED stated it was important to ensure that a dialysis patient had their appointments and resources aligned prior to discharge.

During a concurrent interview and record review on 4/11/24 at 10:15 a.m. with the Director of Emergency Department (EDD), Patient (Pt) 5's medical record was reviewed. The document titled "Emergency Department (ED) care timeline" and "ED physician note" for the ED Visits dated 4/2/24 indicated Pt 5 was brought back to ED by EMS on 4/2/24 at 9:35 a.m. [6 hour and 18 minutes after discharge] due to shortness of breath and patient was hypoxic (state in which oxygen is not available in sufficient amounts at the tissue level) and tachypneic (condition that refers to rapid breathing), on 5 lpm oxygen vial nasal cannula at home. Pt 5 oxygen saturation was at 70% when EMS arrived and transported patient to ED. Pt 5 triaged was completed on 4/2/24 at 9:51 a.m. and ESI of 2 was assigned. The disposition was selected to admit to inpatient on 4/2/24 at 10:57 a.m. Order was placed for CBC, CMP, Troponin on 4/2/24 at 10:25 a.m. On 4/2/24 at 10:57 a.m. admitting physician was assigned, and order was placed to admit patient to inpatient. Lab results at 11:11 a.m. for BUN 53 mg/dL (normal range 8-21), results for Creatinine 9.78 mg/dL (normal range 0.50-1.20). Results for Troponin on 4/2/24 at 12:11 a.m. shows 117 ng/L (normal range: 0-14).

During a review of the facility's policy and procedure (P&P) titled, "Emergency Care Services - Index No. C-7), with a revised date of February, 2024, the P&P indicated, " ...All patients discharged from the Emergency Department will receive appropriate discharge instructions, including information regarding any necessary follow up care and instructions on medication, devices and diagnosis ...The Nurse will involve other resources deemed necessary to facilitate a safe patient discharge, including ...initiating referral to social worker ..."

2. During a review of the hospital's report of returns to Emergency Department (ED) within 48 hours (of a previous ED visit) for April 2024, the report indicated Patient (Pt) 6 was a 25-year-old male who came to the ED at 9:30 p.m. on 4/4/24 with a chief complaint of "[Shortness of breath] and throat pain" and was discharged on 4/5/24 at 3:22 a.m. The report indicated that Pt 6 had returned to the ED on 4/6/24 at 10:24 a.m. with a chief complaint of "Throat pain" and was discharged on 4/6/24 at 11:36. The report indicated Pt 6 returned to the ED third time on 4/7/24 at 5:06 p.m. with a chief complaint of "[shortness of breath] sore throat" and was admitted to the hospital.

During a concurrent interview and record review on 4/11/24 at 11:50 a.m. with the Director of Emergency Department (EDD), Pt 6's medical record was reviewed. The document titled "Emergency Department (ED) care timeline" and "ED physician note" for the ED Visit dated 4/4/24 indicated, Pt 6 was a 25-year-old male, with no primary care physician (PCP), arrived in facility's emergency department (ED) on 4/4/24 at 9:30 p.m. with chief complaint of "shortness of breath." Pt 6's initial vitals on arrival to the ED on 4/4/24 at 9:36 a.m. indicated Heart rate 102 beats per minute (bpm) (normal 60-100 beats per minute), blood pressure 149/88 millimeter of mercury (mmHg - unit of measurement for pressure normal less than 120/80), respirations 16 breaths per minute (normal 12-20). Pt 6 was triaged on 4/4/24 at 10:19 p.m., Pt 6 was assigned an emergency severity index (ESI) level 3 (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed, ESI 1 being the most serious) and Pt 6's chief complaint was updated at 10:19 p.m. to, "Throat pain (Noticed abscess on his tonsils (lymph nodes in the back of the mouth and top of the throat). [Y]esterday morning, pain with swallowing. [History]of Peritonsillar abscess (a common infection of the head and neck region) 01/2024)". Pt 6 had a pain assessment done at 10:20 p.m. and had pain score of 5 (pain scale used to rate a person's pain on a scale of 0 to 10, 0-3 mild pain, 4-6 moderate pain, 7-10 severe pain). Pt 6 had a physician assigned on 4/4/24 at 10:56 p.m. and orders were placed for medication used to treat swelling, penicillin G benzathine IM (medication used to treat bacterial infection), labs- CBC (blood test that measures many different parts often used to help screen overall health and measures the number of types of blood cells) and differential, Basic metabolic panel (BMP-- test to check the body's fluid balance and levels of essential minerals that are vital to key functions in the body), and CT neck soft tissue w Contrast (diagnostic imaging study that combines the use of a high-tech rotating X-ray machine, a contrast dye, and sophisticated computer analysis to produce high-resolution 3D images of the soft tissues in your neck region from the base of your skull to the top of the chest). Pt 6 received medication used to treat swelling on 4/5/24 at 12:01 a.m., and penicillin G benzathine at 12:07 a.m. The CBC results on 4/5/24 at 12:15 a.m. indicated WBC (high WBC indicates most likely infection) 15.8 K/mcl (K/mcl - unit of measurement for thousands of cells per microliter of blood) (normal range 4.5-11), MCV (measures the average size of your red blood cells , helps provider diagnose certain conditions) 95.3 FL (normal range 80-94), MPV (measures the average size of your platelets, help diagnose certain blood disorder) 10.9 FL (normal range 7-10), Neutrophils Relative (indicates infection) 78.8 % ( normal range 51-70), Neutrophils Absolute (used to check for infection, inflammation, leukemia, and other conditions) 12.42 K/mcl (normal range 2.60-8.20), Monocytes Absolute (high level indicates body is fighting infection) 1.16 K/mcl (0.10-1.00). Pt 6's had vital signs and pain reassessment done on 4/5/24 at 12:16 a.m. and pain score remained at 5. Pt 6's BMP results on 4/5/24 at 12:37 a.m. indicated potassium 3.3 millimoles per liter (mmol/L - Unit of measurement -normal range 3.5-5.5). Pt 6's CT Neck soft tissue with contrast done on 4/5/24 at 1:12 a.m. Pt 6 was given medication use to numb and relieve pain during procedure on 4/5/24 at 2:35 a.m. and peritonsillar drainage done by ED physician at 2:39 a.m. Pt 6 was given discharge instructions on 4/5/24 at 2:46 a.m. The discharge after visit summary (AVS) on 4/5/24 at 2:46 a.m. indicated, " ...Start taking: Amoxicillin -clavulantate [antibiotic use to treat infections caused by bacteria] ...Pick up these medication at ...schedule appointment with "No Pcp physicians" as soon as possible for a visit in 1 week (around 4/12/24) ...". Pt 6's vitals on 4/5/24 at 2:59 a.m. indicated heart rate 92 bpm (normal 60-100), respiration 19 breaths per minute (normal 12-20 breaths per minute), Blood pressure 123/73 mmHg (normal less than 120/80). The RN note on 4/5/24 at 3:02 a.m. indicated, "Pt asking for pain meds prior to discharge. [name of doctor] informed through secure chat. Waiting for response". Pt 6 had a pain assessment on 4/5/24 at 3:04 a.m. and Pt 6 had a pain score of 5. Pt 6 was given Hydrocodone -acetaminophen 5-325 1 tablet on 4/5/24 at 3:20 a.m. and Pt 6 was discharged at 3:22 a.m. (2 minutes later) with family.

During a review of Pt 6's "ED physician note," for service date of 4/4/24, the ED physician note indicated, " ...Primary care physician: No Pcp Physician ...25 [year old] male with [history] of [Diabetes Mellitus] presents to ED [complaint of] throat soreness, onset yesterday ...due to Throat pain (Noticed abscess on his tonsil yesterday morning, pain with swallowing. History of Peritonsillar abscess 01/20240) ...CT Neck Soft Tissue w Contrast Final Result Small area of abscess or phlegmon with in the right palatine tonsil [tissue at the entrance of Respiratory tract in the back of throat] ...Procedures Incision and Drainage [procedure to release pus] ...Peritonsillar Abscess Drainage ...Findings: 2 ml of [pus ] material was aspirated with reduction in size of the abscess ...case reviewed with Pt at bedside ...Pt informed of need for follow up with PCP. Questions and concerns were addressed at this time ...Will [discharge] home ...plan ...Discharge ...No Pcp Physician ...schedule an appointment as soon as possible for a visit in 1 week if symptoms worsens ..."

During an interview on 4/11/24 at 1155 with the EDD, the EDD stated, she had reviewed Pt 6's medical record. The EDD stated Pt 6's pain reassessment was not done in accordance with facility's policy. The EDD stated Pt 6 received a pain medication and was discharged without pain reassessment. The EDD stated Pt 6 did not have primary care physician listed in his medical record and there was no indication that reflect Pt 6 received list of clinics for follow up care. The EDD stated Pt 6 should have received list of clinics for follow up care as part of the ED discharge process.

During an interview on 4/11/24 at 2:30 p.m. with the EDMD, the EDMD stated he was the medical director for ED. The EDMD stated he had reviewed Pt 6's medical record with the EDD. The EDMD stated abscess drainage was standard procedure. The EDMD stated he identified opportunities for improvement with provider's documentation in care for Pt 6.

During a concurrent interview and record review on 4/11/24 at 11:57 a.m. with the Director of Emergency Department (EDD), Pt 6's medical record was reviewed. The document titled "Emergency Department (ED) care timeline" and "ED physician note" for the ED Visit dated 4/6/24 indicated, Pt 6 returned to ED on 4/6/24 at 10:24 a.m. (31 hours and 2 minutes after discharge) with the chief complaint of "throat pain". Pt 6's vital on 4/6/24 at 10:27 a.m. indicated heart rate 95 bpm (normal 60-100 bpm), respirations 17 breaths per minute (normal 12-20), blood pressure 128/84 mmHg (normal less than 120/80). Pt 6's pain assessment was done on 4/6/24 at 10:30 a.m. and Pt 6's pain score was at 7. Pt 6 triage was completed on 4/6/24 at 10:30 a.m., ESI of 2 was assigned and Pt 6's chief complaint was updated. The Pt 6 updated chief complaint indicated, "Throat pain (Pt c/o throat pain and states he has abscess to right tonsil dx here in ER 2 days ago. Pt states he is back due to the abscess worsening. Pt is on [antibiotics by mouth] but can only take once a day instead of prescribed twice a day due to increased throat swelling at night. Pt states it is hard to manage his secretions)". Pt 6 was given benzocaine (to numb the lining of the mouth and throat) spray in mouth/throat on 4/6/24 at 11:00 a.m. The Pt 6's pain assessment on 4/6/24 at 11:00 a.m. indicated pain score of 7. Pt 6 was given lidocaine (medication that prevents and treats pain caused by some procedures) on 4/6/24 at 11:01 a.m. Pt 6 had peritonsillar abscess drainage performed on 4/6/24 at 11:12 a.m. and culture was sent to lab. Pt 6 was provided discharge instructions on 4/6/24 at 11:28. Pt 6 was discharged on 4/6/24 at 11:36 a.m.

During a review of Pt 6's after visit summary (AVS) dated 4/6/24, the AVS indicated, " ...follow up with your primary care doctor ... currently have no upcoming appointments scheduled."

During a review of Pt 6's "ED physician note," for service date of 4/6/24, the ED physician note indicated, " ... Primary care physician: No Pcp Physician ...25-year-old male presents to the ED with an abscess, onset 4 days ago. Pt was seen 2 days ago in the ED... Pt states the pain has worsened since he was last seen, and he has not been able to his medications due to swelling ...Right sided peritonsillar swelling, uvala is deviated to the left, consistent with the right sided peritonsillar abscess ...Incision and Drainage ...Peritonsillar Abscess Drainage ...indications: Fluctuant Peritonsillar abscess ...Findings ...4 ml of purulent material was aspirated with reduction in size of the abscess ...complications: none ...Pt informed of peritonsillar abscess diagnosis and need for follow up with PCP ...Questions and concerns were addressed at this time. Will d/c home. Pt understands and agrees to the treatment plan ...Plan ...discharge ...follow up with your primary care [physician] ..."

During an interview with the EDD on 4/11/24 at 12:00 p.m. with the EDD, the EDD stated she had reviewed Pt 6's chart for the ED visit for 4/6/24. The EDD stated she was unable to find any documentation during the second ED visit on 4/6/24 that Pt 6 received resources and list of clinics for follow up care. The EDD stated Pt 6 did not have PCP listed and should have received a list of clinic and resources to establish follow up care after discharge. The EDD also stated she was not able to find any documentation regarding Pt 6's ability to swallow oral antibiotics and no indication a pain assessment was completed before discharge. The EDD stated Pt 6 was not compliant with antibiotics due to difficulty swallowing and had difficulty in managing secretions. The EDD stated although ED physician had documented reduction in size of Pt 6's abscess, she did not know if Pt 6 would be able to continue oral antibiotics or manage his secretions. The EDD stated Pt 6 had pain of 7 at 11:01 a.m. on 4/6/24 and had a peritonsillar abscess drainage performed by an ED physician at 11:12 a.m. Pt 6's vital signs were checked on 4/6/24 at 11:35 a.m. and Pt 6 was discharged at 11:36 a.m. The EDD stated no pain assessment was documented with vital signs at 11:35 a.m.

During a concurrent interview and record review on 4/11/24 at 12:07 p.m. with the EDD, Pt 6's medical record was reviewed. The document titled "Emergency Department (ED) care timeline" and "ED physician note" for the ED Visit dated 4/7/24 indicated, Pt 6 returned to ED on 4/7/24 at 5:06 p.m. (29.5 hours after discharge) with the chief complaint of "shortness of breath, sore throat". Pt 6 had physician assigned at 5:09 p.m. Pt 6's vitals on arrival to ED on 4/7/27 at 5:13 p.m. indicated heart rate 99 bpm (normal 60-100 bpm), respirations 18 breaths per minute (normal 12-20), blood pressure 144/92 mmHg (normal less than 120/80). On 4/7/24 at 5:14 p.m. triage was completed, Pt 6 was assigned an ESI of 3, and chief complaint was updated, "Throat Abscess (Patient here yesterday for peritonsillar abscess, and had it drained. [compliant of] continued throat pain and swelling. Difficulty swallowing.)". Orders were placed on 4/7/24 at 5:24 p.m. for labs, IV (administered into a vein) antibiotics and blood culture (test of blood to check presence of bacteria and other microorganism in the blood). On 4/7/24 at 5:53 p.m. Pt 6 was admitted to in patient.

During a review of Pt 6's "ED physician note," for service date of 4/7/24, the ED physician note indicated, " ...25 [year old] male with [history of] [Diabetes Mellitus] and peritonsillar abscess presents to the ED with [compliant of] a throat abscess with associated pain and swelling onset five days ago. Additional symptoms include difficulty swallowing, talking, and breathing ...The patient was here in the ED yesterday when had the abscess drained, and three days ago when the was given antibiotics, which he states he has not been taking since he has been having trouble swallowing. He states his symptoms are continuing to get worse. Of note, the patient does not have an ENT specialist .... Procedures Incision and Drainage ... The patient was seated with the head slightly extended and supported by the head rest. The Topical anesthetic was introduced over the area of greatest fluctuance on the Left/Right ...Findings: X ml of purulent material was aspirated with reduction in size of abscess. Estimated blood loss: X ml ..."

During an interview on 4/11/24 at 12:10 p.m. with the EDD, the EDD stated she had reviewed Pt 6's chart for the ED visit for 4/7/24. The EDD stated the ED physician note about an incision and drainage appears to be a template and was not updated with Pt 6's procedure findings by the provider. The EDD stated Pt 6 had no primary care physician and was seen three times in the ED, Pt 6 was admitted on his third visit. The EDD stated Pt 6 expressed that he was unable to swallow antibiotics due to swelling and pain and would have benefitted from swallow assessment prior to discharge on the second visit. The EDD stated although the physician note states Pt 6 was stable to discharge, the documentation does not reflect Pt 6's ability to swallow the antibiotics was assessed prior to discharge.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Care Services - Index No. C-7)," with a revised date of February, 2024, the P&P indicated, " ...All patients discharged from the Emergency Department will receive appropriate discharge instructions, including information regarding any necessary follow up care and instructions on medication, devices and diagnosis ...The Nurse will involve other resources deemed necessary to facilitate a safe patient discharge, including ...initiating referral to social worker ...Document vitals within 30 minutes of discharge unless otherwise directed by emergency department provider ..."

During a review of the facility's policy and procedure (P&P) titled, "Pain management guideline," with a revised date of November, 2020, the P&P indicated, " ...at point of entry to facility, an initial pain assessment will be performed. .. The RN will administer analgesia as ordered for the patient's assessment and pain level score using age appropriate and developmental/cognitive function assessment ...Reassessment criterial will be used to evaluate and respond to the patient's pain ...Document reassessment will include pain and sedation levels ...pain will be reassessed and documented 15 minutes after IV pain medication administration and 1 hour after oral medicine administration ...assess and reassess pain at regular intervals appropriate for the specific patient including: ... Following pain management interventions, once sufficient time has elapsed for the treatment (to be effective) ...prior to discharge ..."

3. During a review of the hospital's report of returns to Emergency Department (ED) within 48 hours (of a previous ED visit) for March 2024, the report indicated Pt 7 was a 31-year-old man who came to the ED at 8:48 a.m. on 3/28/24 with a chief complaint of "high blood sugar and abdominal pain" and was discharged on 3/28/24 at 12:18 p.m. The report indicated that Pt 7 had returned to the ED on 3/29/24 at 9:12 p.m. with a chief complaint of "DKA - serious complication of diabetes that can be life threatening , blurred vision."

During a concurrent interview and record review on 4/11/24 at 11:00 a.m. with the Director of Emergency Department (EDD), Pt 7's medical record was reviewed. The document titled "Emergency Department (ED) care timeline" and "ED physician note" for the ED Visit dated 3/28/24 indicated Pt 7 was a 31-year-old male who came to the ED on 3/28/24 at 8:48 a.m. with a chief complaint of "Abdominal pain and high sugar, [Pt 7] stated he was told he had Diabetes and not on any medication". Pt 7's vital signs on arrival to ED on 3/28/24 at 8:54 a.m. indicated, pulse 88 beats per minute (bpm-normal 60-100 bpm), respiratory rate 16 breaths per minutes (normal 12-20), blood pressure 129/83 millimeters of mercury (mmHg)(normal- less than 120/80 mmHg). Pt 7 was triaged at 8:55 a.m. on 3/28/24. Pt 7 was assigned an emergency severity index (ESI) level 3 (ESI- a 5 level scale used by triage nurses to indicate the seriousness of the patient's condition and the resources needed, ESI 1 being the most serious). Pt 7's primary assessment was completed by a nurse at 8:56 a.m. On 3/28/24. Pt 7 was assigned a physician at 9:04 a.m. Lab orders were placed for urinalysis with microscopic reflex culture (test accessing the chemical constituents of urine and detect the presence of abnormal urine cells), magnesium (blood test measures the amount of magnesium in a sample of blood), lipase (test for lipase level in blood, help diagnose disease of pancreas), comprehensive metabolic panel (CMP - a routine blood test that measures 14 different substances in a sample of blood, test to check the body's fluid balance and levels of essential minerals that are vital to key functions in the body), CBC (CBC- blood test that measures many different parts often used to help screen overall health and measures the number of types of blood cells) and differential at 9:20 a.m. The lab results on 3/28/24 on 9:43 a.m. indicated glucose 289 mg/dL (normal range: 70-105), CO2 (test to determine healthcare providers determine if the body is balancing electrolytes properly): 15 mmol/L (normal range: 21-31). Pt 7's urinalysis results on 3/28/24 at 10:12 a.m. indicated abnormal results significant for urinary tract infection (UTI - infection in any part of the urinary system that includes the kidneys, ureters, bladder, and urethra). Pt 7 received IV (liquids injected into a person's vein) Lactated Ringer bolus (fluid used to replace water and electrolyte loss in patients) 1000 ml, received insulin (medication used to regulate blood sugar) subcutaneous (under the skin) injection and cefdinir (antibiotic used to treat bacterial infections) 300 mg capsule on 3/28/24 at 10:13 a.m. Pt 7 received IV ondansetron (medication to prevent nausea and vomiting) on 3/28/24 at 10:27 a.m. Pt 7 vitals were assessed at 12:09 p.m. The EDD stated the only blood glucose check was the