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Based on record review and interview, the facility failed to ensure stabilizing treatment of an identified emergency medical condition for one (Patient #1) of 20 patients reviewed.

This failed practice had the likelihood to result in possible sepsis and organ failure for all patients being discharged from the ED with an active infection. (See C2407)

Based on record review and interview, the facility failed to ensure stabilizing treatment of an identified emergency medical condition for one (Patient #1) of 20 patients reviewed.

This failed practice had the likelihood to result in possible sepsis and organ failure for all patients being discharged from the ED with an active infection.

Findings:

A review of policy titled "EMTALA Policy" read in part, "all health facilities will comply with the Emergency Medical Treatment and Active Labor Act ("EMTALA") 42 U.S.C. 1395 dd, et al... Stabilized for discharge is determined that the individual has reached the point where their continued care could be performed as an outpatient."

Patient #1

A review of the medical record showed:
1) A 10/08/24 emergency department admission date.
2) Presenting complaint was altered mental status.
3) A urinalysis interpretation dated 10/08/24 at 6:03 PM read in part, "Normal except: LEUKOCYTE ESTERASE 2+."
4) The patient received Ceftriaxone 1 gram IV antibiotic while in the ED.
5) An ED discharge diagnosis of urinary tract infection.
6) No documentation a prescription for antibiotics was provided to the patient at discharge on 10/08/24.

Further review of the medical record showed the 10/08/24 urinalysis with abnormal results of a white blood cell count of 21-40 and bacteria at 3+. The urinalysis results reflexed a urine culture dated 10/18/24 at 7:04 AM (10 days later) which read in part, "Result: Greater than 100,000 CFU/mL of Klebsiella."

The medical record also showed physician addendum documentation dated 10/18/24 at 8:50 AM (10 days later) which read in part, "Cefpodoxime called in to Wal-Mart pharmacy 7 day course."

On 03/27/25 at approximately 4:15 PM, Staff N stated:
1) Antibiotics is the standard course of treatment for a urinary tract infection.
2) Depending on the severity of their symptoms, patients may receive IV antibiotics and be sent home, or they may just be discharged with a prescription for antibiotics.
3) Patient #1 did not receive a prescription for antibiotics at discharge on 10/08/24 because they received IV antibiotics which gave them 24 hour coverage and they were going to see a cardiologist the next morning.