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Based on record review and interview, the hospital failed to follow their policy and did not provide an adequate medical screening examination within its capabilities to one individual that presented twice to the emergency department [Patient # 29-A and 29-B] out of 30 patients selected for review from July 1, 2011 to December 20,2011.

Findings include:

Review of the policies and procedures for EMTALA found the policy that was dated 01/23/2009 defined a Medical Screening Examination as meaning "the screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist." The policy further directs "The Hospital will provide an appropriate 'medical screening examination' within the capacity of the Hospital's 'dedicated emergency department' including ancillary services routinely available, to determine whether or not an 'emergency medical condition' exists."

Review of the hospital's data base information completed by a Service Line Administrator on 12/21/2011 documented the hospital is a designated Level 1 Trauma Center and has ancillary services that include a full laboratory/pathology department, radiology, nuclear medicine, ultrasound, electro-cardiogram, full cardiac services, full surgical services, and other services to meet the needs of all patients for the emergency department and labor and delivery.

Review of Patient 29-A's emergency room records revealed the patient visited the ED on 12/8/2011 with complaints of abdominal pain, painful breathing, cough, nausea and diarrhea, and right leg pain for several days. Patient 29 had a known history of deep venous thrombosis [DVT]. A DVT is a blood clot in a deep vein of a lower extremity. Documentation in the record indicated he had not been taking his Coumadin [blood thinning medication] for several months. The emergency department physician [MD-B] examined Patient 29-A, and ordered multiple blood tests including one to evaluate the clotting tendencies of his blood. The lab test revealed Patient 29-A had a sub-therapeutic INR ratio of 1.07 (therapeutic 2.00 - 3.00) and was not adequately protected from developing a DVT or from a blood clot moving through the blood stream to his lungs [pulmonary embolus (PE)]. MD-B diagnosed the patient with gastroenteritis and an upper respiratory infection and wrote an order for discharge. Review of the documentation of the tests ordered and the examination completed revealed the ED did not perform an adequate medical screening examination to exclude a DVT or a PE in a patient with a past history of DVTs. If not treated appropriately, a DVT or PE could result in significant morbidity and even death. Refer to tag A2406 for further details.

Review of Patient 29-B's visit on 12/11/2011 revealed he complained of coughing up dark red blood, that he had a history of DVTs and had not been taking his Coumadin 10 mg daily as prescribed for 4 to 6 months. The documentation of the medical screening examination revealed no tests were ordered and there was not anything in the examination of the patient to rule out a DVT or PE. The patient was again discharged home without an adequate medical screening examination. Refer to tag A2406 for further details.

Patient 29 was seen in another hospital's ED on 12/13/2011 and found to have DVTs in both legs, a pulmonary embolus and pneumonia. Patient 29 was in critical condition and was admitted to that hospital.

An interview with Patient 29 on 12/16/2011 at 11:30 AM revealed the patient felt he had not received the care he required and regarding the second visit he stated "All they did was take my vital signs. They didn't do any lab or anything. If I hadn't come here I could have died."

Based on record review and interview, the hospital failed to provide an adequate medical screening examination within its capabilities to one individual that presented twice to the emergency department [Patient # 29-A and 29-B] out of 30 patients selected for review from patients seen in the emergency department between July 1, 2011 and December 20, 2011.

Findings include:

Review of the medical record revealed Patient 29-A presented to the emergency department [ED] on 12/8/2011 at 8:01 PM complaining of abdominal pain in addition to a cough and painful breathing. Further documentation revealed Patient 29-A also complained of right leg pain and that he had a history of deep vein thrombosis [DVT]. DVT is defined as a blood clot that blocks blood flow in the large veins, mainly of the lower leg or thigh. The ED registered nurse [RN-A] documented the patient stated his right leg had been painful for "the last couple of days" and that he had been prescribed Coumadin [a medication used to prevent blood clots]. Further documentation revealed the patient had not taken the Coumadin for 2 months. The emergency department physician [MD-B] examined Patient 29-A, and ordered multiple blood tests including one to evaluate the clotting tendencies of his blood. The lab test revealed Patient 29-A had a sub-therapeutic INR ratio of 1.07 (therapeutic 2.00 - 3.00) and was not adequately protected from developing a DVT or from a blood clot moving through the blood stream to his lungs [pulmonary embolus]. MD-B diagnosed the patient as having gastroenteritis and an upper respiratory infection. Patient 29-A was provided with a prescription for a pain medication (Lortab), and instructed to take Mucinex and Robitussin cough syrup. The patient was also instructed to follow up with his primary care physician within 14 days regarding his prescription for Coumadin. The medical record did not contain evidence the ED performed within its capabilities, Doppler studies of the patient ' s painful leg, or a CT angiogram of the chest or VQ scan (radiologic studies) to detect or exclude the presence of a DVT or pulmonary embolus in a patient with a past history of DVTs. If not treated appropriately, a DVT or pulmonary embolus could result in significant morbidity and even death.

Review of the medical record revealed Patient 29-B returned to the ED on 12/11/2011 at 4:12 PM and complained of coughing up dark red blood [hemoptysis], that he had a history of DVTs and had not been taking his Coumadin 10 mg daily as prescribed for 4 to 6 months. Further documentation indicated Patient 29 had been seen in the ED 3 days prior and was diagnosed with bronchitis. ED physician assistant [PA-C] examined the patient but did not perform any lab or radiologic testing. PA-C documented that Patient 29-B had hemoptyis and that his bronchitis was resolving, and discharged him with pre-printed instructions on Bronchitis and Hemoptysis. The medical record did not contain evidence that PA-C performed an adequate medical screening examination to exclude a pulmonary embolus [hemoptysis is a well known symptom of a pulmonary embolus] in a patient that was not taking his Coumadin (inadequately protected from forming blood clots).

An interview with Patient 29 was completed on 12/16/2011 at 11:30 AM. Patient 29 stated "I went to [ED] on Sunday [12/11/2011] coughing up blood and they know I get blood clots. All they did is one set of vital signs. They didn't do any lab test or anything." The patient revealed he felt sicker and decided to go to a different ED (Hospital B). He said he was admitted [to Hospital B] because he had DVT's in both legs, a pulmonary embolism and pneumonia. The patient felt they had not provided the care that was needed and that he "could have died" if he hadn't gone to another hospital for help.

An interview with PA-C was completed on 12/23/2011 at 1:10 PM. PA-C stated Patient 29 complained of "coughing up dark red stuff, but was not in any distress." Patient 29 told him he came in because he wanted to make sure he shouldn't be worried about it. PA-C said his exam was within normal limits and the patient had improved since the prior visit on 12/8/2011. The complaint of coughing up blood had not persisted. PA-C said he had looked at the labs and x-ray results from the visit on the 8th and during his exam did not find any reason to repeat or order other tests. PA-C felt comfortable with what was done.

An interview with the ED physician [MD-D] supervising PA-C was completed on 12/23/2011 at 1:10 PM. MD-D stated agreement with what PA-C had done. MD-D had reviewed the chart and had talked with PA-C prior to this interview and based on that had thought the only other thing that could have been done was a chest x-ray. However in reviewing the previous x-ray done 2 days earlier that had been with-in-normal limits, and that PA-C had found the patient's lungs were clear, there was no indication to repeat the x-rays.

An interview was completed with the Director of the Emergency Department [RN-E] on 12/22/2011 at 3:40 PM regarding Patient 29. RN-E stated that Patient 29 had been in the ED a number of times, but was not considered a frequent flyer, and was thought to be reliable and truthful. RN-E stated they had done a lot of tests on 12/8/2011. While he was in the ED on 12/11/2011 he did not cough up any blood or sputum. His vital signs were stable, not any different than on the prior visit and that was why none of the tests were repeated.

Review of Hospital B ' s medical record revealed Patient 29 presented on 12/13/2011 at 12:41 PM and was diagnosed with DVTs, pulmonary emboli, and pneumonia and admitted for stabilizing treatment of his emergency medical condition.