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Based on findings from document reviews, in 1 of 27 medical records (MRs) reviewed, the medical screening exam (MSE) completed on a patient (Patient A) during an emergency department (ED) visit did not identify the patient's potentially septic condition and resulted in discharge of the patient in an unstable condition.

Findings include:

-- Per review of Patient A's MR, this 89 year old patient presented to the ED at 0020 with altered mental status. Vital signs (VS) at triage were temperature (T) 98.5, respirations (R) 18, pulse (P) 89, blood pressure (BP) 102/60. Documentation by the Triage Nurse indicated Patient A had been diagnosed with a urinary tract infection (UTI) that same day and placed on Cipro.

The ED Physician examined the patient at 0100 and indicated information was obtained from family due to Patient A's dementia, and that there were "no acute findings." Complete blood count (CBC) with differential, comprehensive metabolic panel (CMP), urinalysis (UA), and thyroid cascade tests were ordered at 0120, as well as bolus administration of 1 liter of normal saline IV (intravenously).

The lab results at 0155 included the following:
* white blood count (WBC) 15.2 (normal 4.1-11.0)
* neutophils 82% (normal 35-75%)
* bands 9% (normal 0-11%).
* glucose 162 (normal 70-99)
* BUN (blood urea nitrogen) 42 (normal 7-24)
* creatinine 1.4. (normal 0.6-1.0)

The UA results at 0215 included:
* WBC 50-100 (normal 0-5)
* bacteria 4+ (normal 0)
* protein 1+ (normal 0)

Nursing documentation indicates Patient A received the 1000 cc bolus of normal saline ordered via #22 gauge saline lock in the left hand, a Foley catheter was inserted, and total output was 225 cc (plus bowel incontinence).

Patient A's VSs were as follows:
* 0240 - T 98.3, P 92, R 16 and BP 97/64
* 0320 - P 81, R16, and BP 94/62 (no T documented)

At 0340, even though the patient's BP was gradually decreasing despite having received 1000 cc normal saline, nursing documentation indicates Patient A was discharged home "in stable condition" via wheelchair with family.

Physician documentation indicates the patient was discharged with diagnosis of a UTI.

Patient A returned to the ED at 1030 later that day, in full arrest; resuscitation was not successful.