HospitalInspections.org

Based on medical record review, review of a letter to the facility, facility policy review and interview, the facility failed to comply with EMTALA regulations by failing to perform an assessment according to accepted medical standards; failing to provide care in a timely manner; and failing to transfer a patient when the facility no longer had the capability to care for the patient for one (#5) of twenty-eight patients reviewed.

The findings included:

Medical record review revealed patient #5 presented to the Emergency Department (ED) of facility #1 on March 9, 2013, at 2:10 p.m. with complaints of passing blood clots rectally since 10:00 a.m., as well as back and abdominal pain.

Review of the initial ED nursing assessment revealed the patient's pain was 7/10 with 10 being the highest level of pain. Continued review of the nursing assessment revealed the patient stated the pain was aching and throbbing and was located in both lower quadrants of the abdomen. Further review of the nursing assessment revealed the pain did not radiate. Continued review of the nursing assessment revealed the patient's abdomen was tender to palpation in both right and left lower quadrants.

Review of the Physician Documentation from the ED revealed "...presents to ED via walk-in with complaints of abdominal pain, back pain. Symptoms/episode began/occurred acutely 4 hours ago. The symptoms do not radiate. Associated signs and symptoms: none..."

Review of the Certification of Medical Screening Examination revealed "...the patient's condition is such that the patient DOES HAVE an Emergency Medical Condition (EMC) requiring further emergency medical evaluation, treatment, and/or stabilization. The EMC was GI Bleed..." and was signed by the ED physician.

Review of laboratory studies completed on March 9, 2013, revealed a white blood count of 20.2 (normal 4.8 - 10.8); hemoglobin 14.4 (normal 11.7 - 16.1); hematocrit 41.0 (normal 35.0 - 47.0). Continued review of laboratory studies revealed a urinalysis was negative.

Review of a Computerized Tomography (CT) of the abdomen and pelvis revealed "...the bowel and mesentery are unremarkable with no evidence of obstruction..."

Review of discharge instructions given on March 9, 2013, at 5:38 p.m. revealed a diagnosis of sinusitis with discharge medications to include Toradol (Pain medication)10 mg (milligrams) 5 pills ordered to be taken orally once daily not to exceed 4 tablets in 24 hours and Zithromax 250 mg oral tablets 2 to be taken one time then one tablet daily for 4 days. Further review of the physician documentation revealed c/o (complained of) sinus pressure and on examination "...pressure in paranasal sinuses..." was hand written on the printed copy of the physician documentation form.

Medical record review from hospital #2 revealed the patient arrived on March 9, 2013, at 7:13 p.m. Continued medical record review revealed, on physical examination, the resident's abdomen to be protuberant, slightly distended, and tight with hypoactive bowel sounds. Continued review revealed a rectal examination was performed and stool was guiac positive (blood present in the stool). Further medical record review revealed the patient was admitted to facility #2 and underwent colonoscopy which demonstrated "...severe inflammation found in descending colon and transverse colon secondary to ischemic colitis..." Continued medical record review revealed the patient was admitted to hospital #2, treated and discharged home on March 13, 2012.

Review of the letter dated March 18, 2013, sent by patient #5 to facility #1, revealed the patient's personal physician had told physician #1 to transfer the patient to hospital #2, but since all diagnostic tests were normal physician #1 felt the patient could go home and prescribed an antibiotic for a sinus infection in case that was the cause of the high white blood cell count. Continued review of the patient's letter revealed the patient and spouse were on the way to their car (after being discharged from the ED at facility #1) when the bleeding started again so the patient came into the facility and used the restroom. Further review of the letter revealed the bottom of the toilet was filled with black clots and the rest of the bowl was dark red. Continued review revealed the patient's spouse went into the ED to tell them what was going on. Further review revealed one nurse started to get up but physician #1 said to stay and told the spouse if the patient wanted to come back to the ED for more blood tests the patient could do that or the spouse could take the patient to facility #2. Continued review of the letter revealed while en route to facility #2, the patient felt pressure building up in the back and asked a County Deputy to call an ambulance to transport the patient to facility #2 on March 9, 2013. Further review of the letter revealed the patient was admitted to facility #2 and remained there until March 13, 2013.

Interview with the Director of ED at hospital #1 on March 27, 2012, at 2:55 p.m., in the director's office, revealed the first time the Director was aware of a problem with patient #5 was when a letter from the patient dated March 18, 2013, was shared with the Director. Continued interview revealed if a nurse disagrees with a physician about care issues or discharge the nurse needs to speak with the physician. Continued interview revealed if that does not work the nurse can call the patient's personal physician and notify the house supervisor. Further interview revealed the nurse may contact the Administrator on Call who has access to the Chief of Staff.

Continued interview with the Director of ED revealed if a patient were to come to the ED passing clots the nurse ought to be very concerned. Continued interview revealed all nurses know they cannot tell a patient to go to a higher level of care.

Further interview with the Director of the ED revealed if a nurse was told a patient had passed blood and clots in a public bathroom outside the ED in hospital #1 it was an expectation the nurse would go to investigate. Continued interview with the Director of the ED revealed "...If someone requests assistance you are obligated to check it out..."

Interview with the Registered Nurse (RN) who was the patient's primary nurse in the ED of facility #1 on March 27, 2012, at 3:10 p.m., in the ED Director's office, revealed the nurse was unable to recall patient #5 either by description or by name. Continued interview revealed if the nurses didn't agree with the physician's discharge decision the nurse would ask the doctor why...made that particular decision and ask the physician if this had been discussed with the resident and family. Continued interview with RN #1 revealed if a patient was passing blood clots the nurse would observe vital signs or a decrease in blood pressure and increase in pulse, and would suggest to the physician the patient needed to be transferred to a higher level of care.

Interview with physician #1 who cared for the patient on March 9, 2013, confirmed physician #1 was the physician on duty at facility #1's ED on March 9, 2012. Continued interview with physician #1 revealed the physician was unable to recall the patient. After reviewing the patient's record, physician #1 stated "...I remember having to go back in the record because"...had some sinusitis and I ordered antibiotics. Someone asked why the patient was on antibiotics..." Further interview revealed physician #1 talked to the patient's personal physician who felt since the patient was stable (vital signs stable, no further bleeding) the patient could be discharged home. Continued interview with physician #1 revealed "...If I had known...had more bleeding before...left I would have brought...back. Physicians here do not do scopes (insertion of a flexible tube passed through the anus for endoscopic examination of the large bowel and distal small bowel) and if...had come back with bleeding I'm sure I would have done something, transferred...to hospital #2." Further interview with physician #1 confirmed there was no documentation in the medical record to indicate physician #1 spoke with the patient's personal physician.

Interview with the Director of Risk Management at facility #1 on March 28, 2012, at 8:45 a.m., in the conference room revealed the Director had taken the patient's letter very seriously. Continued interview revealed the Medical Director of the ED reviewed the patient's record who stated more treatment should have been done. Further interview revealed the radiologist over-read the CT scan and agreed with the findings.

Interview with the Director of the ED at facility #1 on March 28, 2013, at 10:50 a.m., in the Director's office, revealed as soon as the Director heard of the incident, the Director conducted an inservice for all staff to reiterate they cannot be told by a physician not to check on a patient. Continued interview revealed the Director shared the letter from the patient with the Medical Director of the ED. Further interview revealed none of the staff can remember the incident on March 9, 2013, (when patient #5 had gone into the restroom and passed bloody stool) so no one knows who physician #1 was speaking to when telling the nurse not to check on the patient because the patient was discharged.

Interview with the Medical Director of the ED at facility #1 on March 28, 2013, at 11:00 a.m., in the director's office, revealed the protocol for assessing a patient complaining of abdominal pain and passing clots was to order blood work: complete blood count to assess hemoglobin and hematocrit which may have decreased from the bleeding; complete metabolic panel to assess electrolytes; rectal examination to determine evidence of bleeding; guaiac of stool to determine if there is blood in the stool; and a CT scan of the abdomen. Further interview with the Medical Director revealed when the physician was told the patient had passed blood and clots in the bathroom the physician should have had the patient sign back into the ED for re-evaluation. Continued interview with the Medical Director revealed "...the most medically sound action would be to re-evaluate the patient..." Further interview with the Medical Director, who re-reviewed the medical record at the same time, confirmed there was no documentation of a rectal examination and "...this would be part of an examination for GI bleed..."Further interview with the Medical Director confirmed there was no stool hemocult (test for blood in the stool) ordered - the staff collects the specimen but the laboratory interprets it. Further interview with the Medical Director revealed a physician's order is required for the stool interpretation and confirmed there was no order in the medical record. Continued interview with the Medical Director revealed there was no documentation in the patient's record by the physician of a patient history related to sinusitis; no documentation in the patient examination of sinusitis or complaints of sinus problems; and "...no pathway to get to sinusitis..." Further interview with the Medical Director revealed abdominal pain was not documented as a final diagnosis and "...nothing was documented at discharge to address the initial complaint..."

Based on medical record review, review of a letter to the facility, facility policy review and interview, the facility failed to offer further treatment to stabilize a patient with a potentially life-threatening condition for one (#5) of twenty-eight patients reviewed.

The findings included:

Medical record review revealed patient #5 presented to the Emergency Department (ED) of facility #1 on March 9, 2013, at 2:10 p.m. with complaints of passing blood clots rectally since 10:00 a.m., as well as back and abdominal pain.

Review of the initial ED nursing assessment revealed the patient's pain was 7/10 with 10 being the highest level of pain. Continued review of the nursing assessment revealed the patient stated the pain was aching and throbbing and was located in both lower quadrants of the abdomen. Further review of the nursing assessment revealed the pain did not radiate. Continued review of the nursing assessment revealed the patient's abdomen was tender to palpation in both right and left lower quadrants.

Review of the Physician Documentation from the ED revealed "...presents to ED via walk-in with complaints of abdominal pain, back pain. Symptoms/episode began/occurred acutely 4 hours ago. The symptoms do not radiate. Associated signs and symptoms: none..."

Review of the Certification of Medical Screening Examination revealed "...the patient's condition is such that the patient DOES HAVE an Emergency Medical Condition (EMC) requiring further emergency medical evaluation, treatment, and/or stabilization. The EMC was GI Bleed..." and was signed by the ED physician.

Review of laboratory studies completed on March 9, 2013, revealed a white blood count of 20.2 (normal 4.8 - 10.8); hemoglobin 14.4 (normal 11.7 - 16.1); hematocrit 41.0 (normal 35.0 - 47.0). Continued review of laboratory studies revealed a urinalysis was negative.

Review of a Computerized Tomography (CT) of the abdomen and pelvis revealed "...the bowel and mesentery are unremarkable with no evidence of obstruction..."

Review of discharge instructions given on March 9, 2013, at 5:38 p.m. revealed a diagnosis of sinusitis with discharge medications to include Toradol (Pain medication)10 mg (milligrams) 5 pills ordered to be taken orally once daily not to exceed 4 tablets in 24 hours and Zithromax 250 mg oral tablets 2 to be taken one time then one tablet daily for 4 days. Further review of the physician documentation revealed c/o (complained of) sinus pressure and on examination "...pressure in paranasal sinuses..." was hand written on the printed copy of the physician documentation form.

Medical record review from hospital #2 revealed the patient arrived on March 9, 2013, at 7:13 p.m. Continued medical record review revealed, on physical examination, the resident's abdomen to be protuberant, slightly distended, and tight with hypoactive bowel sounds. Continued review revealed a rectal examination was performed and stool was guiac positive (blood present in the stool). Further medical record review revealed the patient was admitted to facility #2 and underwent colonoscopy which demonstrated "...severe inflammation found in descending colon and transverse colon secondary to ischemic colitis..." Continued medical record review revealed the patient was admitted to hospital #2, treated and discharged home on March 13, 2012.

Review of the letter dated March 18, 2013, sent by patient #5 to facility #1, revealed the patient's personal physician had told physician #1 to transfer the patient to hospital #2, but since all diagnostic tests were normal physician #1 felt the patient could go home and prescribed an antibiotic for a sinus infection in case that was the cause of the high white blood cell count. Continued review of the patient's letter revealed the patient and spouse were on the way to their car (after being discharged from the ED at facility #1) when the bleeding started again so the patient came into the facility and used the restroom. Further review of the letter revealed the bottom of the toilet was filled with black clots and the rest of the bowl was dark red. Continued review revealed the patient's spouse went into the ED to tell them what was going on. Further review revealed one nurse started to get up but physician #1 said to stay and told the spouse if the patient wanted to come back to the ED for more blood tests the patient could do that or the spouse could take the patient to facility #2. Continued review of the letter revealed while en route to facility #2, the patient felt pressure building up in the back and asked a County Deputy to call an ambulance to transport the patient to facility #2 on March 9, 2013. Further review of the letter revealed the patient was admitted to facility #2 and remained there until March 13, 2013.

Interview with the Director of ED at hospital #1 on March 27, 2012, at 2:55 p.m., in the director's office, revealed the first time the Director was aware of a problem with patient #5 was when a letter from the patient dated March 18, 2013, was shared with the Director. Continued interview revealed if a nurse disagrees with a physician about care issues or discharge the nurse needs to speak with the physician. Continued interview revealed if that does not work the nurse can call the patient's personal physician and notify the house supervisor. Further interview revealed the nurse may contact the Administrator on Call who has access to the Chief of Staff.

Continued interview with the Director of ED revealed if a patient were to come to the ED passing clots the nurse ought to be very concerned. Continued interview revealed all nurses know they cannot tell a patient to go to a higher level of care.

Further interview with the Director of the ED revealed if a nurse was told a patient had passed blood and clots in a public bathroom outside the ED in hospital #1 it was an expectation the nurse would go to investigate. Continued interview with the Director of the ED revealed "...If someone requests assistance you are obligated to check it out..."

Interview with the Registered Nurse (RN) who was the patient's primary nurse in the ED of facility #1 on March 27, 2012, at 3:10 p.m., in the ED Director's office, revealed the nurse was unable to recall patient #5 either by description or by name. Continued interview revealed if the nurses didn't agree with the physician's discharge decision the nurse would ask the doctor why...made that particular decision and ask the physician if this had been discussed with the resident and family. Continued interview with RN #1 revealed if a patient was passing blood clots the nurse would observe vital signs or a decrease in blood pressure and increase in pulse, and would suggest to the physician the patient needed to be transferred to a higher level of care.

Interview with physician #1 who cared for the patient on March 9, 2013, confirmed physician #1 was the physician on duty at facility #1's ED on March 9, 2012. Continued interview with physician #1 revealed the physician was unable to recall the patient. After reviewing the patient's record, physician #1 stated "...I remember having to go back in the record because"...had some sinusitis and I ordered antibiotics. Someone asked why the patient was on antibiotics..." Further interview revealed physician #1 talked to the patient's personal physician who felt since the patient was stable (vital signs stable, no further bleeding) the patient could be discharged home. Continued interview with physician #1 revealed "...If I had known...had more bleeding before...left I would have brought...back. Physicians here do not do scopes (insertion of a flexible tube passed through the anus for endoscopic examination of the large bowel and distal small bowel) and if...had come back with bleeding I'm sure I would have done something, transferred...to hospital #2." Further interview with physician #1 confirmed there was no documentation in the medical record to indicate physician #1 spoke with the patient's personal physician.

Interview with the Director of Risk Management at facility #1 on March 28, 2012, at 8:45 a.m., in the conference room revealed the Director had taken the patient's letter very seriously. Continued interview revealed the Medical Director of the ED reviewed the patient's record who stated more treatment should have been done. Further interview revealed the radiologist over-read the CT scan and agreed with the findings.

Interview with the Director of the ED at facility #1 on March 28, 2013, at 10:50 a.m., in the Director's office, revealed as soon as the Director heard of the incident, the Director conducted an inservice for all staff to reiterate they cannot be told by a physician not to check on a patient. Continued interview revealed the Director shared the letter from the patient with the Medical Director of the ED. Further interview revealed none of the staff can remember the incident on March 9, 2013, (when patient #5 had gone into the restroom and passed bloody stool) so no one knows who physician #1 was speaking to when telling the nurse not to check on the patient because the patient was discharged.

Interview with the Medical Director of the ED at facility #1 on March 28, 2013, at 11:00 a.m., in the director's office, revealed the protocol for assessing a patient complaining of abdominal pain and passing clots was to order blood work: complete blood count to assess hemoglobin and hematocrit which may have decreased from the bleeding; complete metabolic panel to assess electrolytes; rectal examination to determine evidence of bleeding; guaiac of stool to determine if there is blood in the stool; and a CT scan of the abdomen. Further interview with the Medical Director revealed when the physician was told the patient had passed blood and clots in the bathroom the physician should have had the patient sign back into the ED for re-evaluation. Continued interview with the Medical Director revealed "...the most medically sound action would be to re-evaluate the patient..." Further interview with the Medical Director, who re-reviewed the medical record at the same time, confirmed there was no documentation of a rectal examination and "...this would be part of an examination for GI bleed..."Further interview with the Medical Director confirmed there was no stool hemocult (test for blood in the stool) ordered - the staff collects the specimen but the laboratory interprets it. Further interview with the Medical Director revealed a physician's order is required for the stool interpretation and confirmed there was no order in the medical record. Continued interview with the Medical Director revealed there was no documentation in the patient's record by the physician of a patient history related to sinusitis; no documentation in the patient examination of sinusitis or complaints of sinus problems; and "...no pathway to get to sinusitis..." Further interview with the Medical Director revealed abdominal pain was not documented as a final diagnosis and "...nothing was documented at discharge to address the initial complaint..."

Based on medical record review, review of a letter to the facility, facility policy review and interview, the facility failed to conduct an adequate screening examination for a patient resulting in a delay in treatment for one (#5) of twenty-eight patients reviewed.

The findings included:

Medical record review revealed patient #5 presented to the Emergency Department (ED) of facility #1 on March 9, 2013, at 2:10 p.m. with complaints of passing blood clots rectally since 10:00 a.m., as well as back and abdominal pain.

Review of the initial ED nursing assessment revealed the patient's pain was 7/10 with 10 being the highest level of pain. Continued review of the nursing assessment revealed the patient stated the pain was aching and throbbing and was located in both lower quadrants of the abdomen. Further review of the nursing assessment revealed the pain did not radiate. Continued review of the nursing assessment revealed the patient's abdomen was tender to palpation in both right and left lower quadrants.

Review of the Physician Documentation from the ED revealed "...presents to ED via walk-in with complaints of abdominal pain, back pain. Symptoms/episode began/occurred acutely 4 hours ago. The symptoms do not radiate. Associated signs and symptoms: none..."

Review of the Certification of Medical Screening Examination revealed "...the patient's condition is such that the patient DOES HAVE an Emergency Medical Condition (EMC) requiring further emergency medical evaluation, treatment, and/or stabilization. The EMC was GI Bleed..." and was signed by the ED physician.

Review of laboratory studies completed on March 9, 2013, revealed a white blood count of 20.2 (normal 4.8 - 10.8); hemoglobin 14.4 (normal 11.7 - 16.1); hematocrit 41.0 (normal 35.0 - 47.0). Continued review of laboratory studies revealed a urinalysis was negative.

Review of a Computerized Tomography (CT) of the abdomen and pelvis revealed "...the bowel and mesentery are unremarkable with no evidence of obstruction..."

Review of discharge instructions given on March 9, 2013, at 5:38 p.m. revealed a diagnosis of sinusitis with discharge medications to include Toradol (Pain medication)10 mg (milligrams) 5 pills ordered to be taken orally once daily not to exceed 4 tablets in 24 hours and Zithromax 250 mg oral tablets 2 to be taken one time then one tablet daily for 4 days. Further review of the physician documentation revealed c/o (complained of) sinus pressure and on examination "...pressure in paranasal sinuses..." was hand written on the printed copy of the physician documentation form.

Medical record review from hospital #2 revealed the patient arrived on March 9, 2013, at 7:13 p.m. Continued medical record review revealed, on physical examination, the resident's abdomen to be protuberant, slightly distended, and tight with hypoactive bowel sounds. Continued review revealed a rectal examination was performed and stool was guiac positive (blood present in the stool). Further medical record review revealed the patient was admitted to facility #2 and underwent colonoscopy which demonstrated "...severe inflammation found in descending colon and transverse colon secondary to ischemic colitis..." Continued medical record review revealed the patient was admitted to hospital #2, treated and discharged home on March 13, 2012.

Review of the letter dated March 18, 2013, sent by patient #5 to facility #1, revealed the patient's personal physician had told physician #1 to transfer the patient to hospital #2, but since all diagnostic tests were normal physician #1 felt the patient could go home and prescribed an antibiotic for a sinus infection in case that was the cause of the high white blood cell count. Continued review of the patient's letter revealed the patient and spouse were on the way to their car (after being discharged from the ED at facility #1) when the bleeding started again so the patient came into the facility and used the restroom. Further review of the letter revealed the bottom of the toilet was filled with black clots and the rest of the bowl was dark red. Continued review revealed the patient's spouse went into the ED to tell them what was going on. Further review revealed one nurse started to get up but physician #1 said to stay and told the spouse if the patient wanted to come back to the ED for more blood tests the patient could do that or the spouse could take the patient to facility #2. Continued review of the letter revealed while en route to facility #2, the patient felt pressure building up in the back and asked a County Deputy to call an ambulance to transport the patient to facility #2 on March 9, 2013. Further review of the letter revealed the patient was admitted to facility #2 and remained there until March 13, 2013.

Interview with the Director of ED at hospital #1 on March 27, 2012, at 2:55 p.m., in the director's office, revealed the first time the Director was aware of a problem with patient #5 was when a letter from the patient dated March 18, 2013, was shared with the Director. Continued interview revealed if a nurse disagrees with a physician about care issues or discharge the nurse needs to speak with the physician. Continued interview revealed if that does not work the nurse can call the patient's personal physician and notify the house supervisor. Further interview revealed the nurse may contact the Administrator on Call who has access to the Chief of Staff.

Continued interview with the Director of ED revealed if a patient were to come to the ED passing clots the nurse ought to be very concerned. Continued interview revealed all nurses know they cannot tell a patient to go to a higher level of care.

Further interview with the Director of the ED revealed if a nurse was told a patient had passed blood and clots in a public bathroom outside the ED in hospital #1 it was an expectation the nurse would go to investigate. Continued interview with the Director of the ED revealed "...If someone requests assistance you are obligated to check it out..."

Interview with the Registered Nurse (RN) who was the patient's primary nurse in the ED of facility #1 on March 27, 2012, at 3:10 p.m., in the ED Director's office, revealed the nurse was unable to recall patient #5 either by description or by name. Continued interview revealed if the nurses didn't agree with the physician's discharge decision the nurse would ask the doctor why...made that particular decision and ask the physician if this had been discussed with the resident and family. Continued interview with RN #1 revealed if a patient was passing blood clots the nurse would observe vital signs or a decrease in blood pressure and increase in pulse, and would suggest to the physician the patient needed to be transferred to a higher level of care.

Interview with physician #1 who cared for the patient on March 9, 2013, confirmed physician #1 was the physician on duty at facility #1's ED on March 9, 2012. Continued interview with physician #1 revealed the physician was unable to recall the patient. After reviewing the patient's record, physician #1 stated "...I remember having to go back in the record because"...had some sinusitis and I ordered antibiotics. Someone asked why the patient was on antibiotics..." Further interview revealed physician #1 talked to the patient's personal physician who felt since the patient was stable (vital signs stable, no further bleeding) the patient could be discharged home. Continued interview with physician #1 revealed "...If I had known...had more bleeding before...left I would have brought...back. Physicians here do not do scopes (insertion of a flexible tube passed through the anus for endoscopic examination of the large bowel and distal small bowel) and if...had come back with bleeding I'm sure I would have done something, transferred...to hospital #2." Further interview with physician #1 confirmed there was no documentation in the medical record to indicate physician #1 spoke with the patient's personal physician.

Interview with the Director of Risk Management at facility #1 on March 28, 2012, at 8:45 a.m., in the conference room revealed the Director had taken the patient's letter very seriously. Continued interview revealed the Medical Director of the ED reviewed the patient's record who stated more treatment should have been done. Further interview revealed the radiologist over-read the CT scan and agreed with the findings.

Interview with the Director of the ED at facility #1 on March 28, 2013, at 10:50 a.m., in the Director's office, revealed as soon as the Director heard of the incident, the Director conducted an inservice for all staff to reiterate they cannot be told by a physician not to check on a patient. Continued interview revealed the Director shared the letter from the patient with the Medical Director of the ED. Further interview revealed none of the staff can remember the incident on March 9, 2013, (when patient #5 had gone into the restroom and passed bloody stool) so no one knows who physician #1 was speaking to when telling the nurse not to check on the patient because the patient was discharged.

Interview with the Medical Director of the ED at facility #1 on March 28, 2013, at 11:00 a.m., in the director's office, revealed the protocol for assessing a patient complaining of abdominal pain and passing clots was to order blood work: complete blood count to assess hemoglobin and hematocrit which may have decreased from the bleeding; complete metabolic panel to assess electrolytes; rectal examination to determine evidence of bleeding; guaiac of stool to determine if there is blood in the stool; and a CT scan of the abdomen. Further interview with the Medical Director revealed when the physician was told the patient had passed blood and clots in the bathroom the physician should have had the patient sign back into the ED for re-evaluation. Continued interview with the Medical Director revealed "...the most medically sound action would be to re-evaluate the patient..." Further interview with the Medical Director, who re-reviewed the medical record at the same time, confirmed there was no documentation of a rectal examination and "...this would be part of an examination for GI bleed..."Further interview with the Medical Director confirmed there was no stool hemocult (test for blood in the stool) ordered - the staff collects the specimen but the laboratory interprets it. Further interview with the Medical Director revealed a physician's order is required for the stool interpretation and confirmed there was no order in the medical record. Continued interview with the Medical Director revealed there was no documentation in the patient's record by the physician of a patient history related to sinusitis; no documentation in the patient examination of sinusitis or complaints of sinus problems; and "...no pathway to get to sinusitis..." Further interview with the Medical Director revealed abdominal pain was not documented as a final diagnosis and "...nothing was documented at discharge to address the initial complaint..."

Based on medical record review, review of a letter to the facility, facility policy review, and interview, the facility failed to transfer a patient to a higher level of care when their resources were exhausted and the facility lacked the capability to treat the patient for one (#5) of twenty-eight residents reviewed.

The findings included:

Medical record review revealed patient #5 presented to the Emergency Department (ED) of facility #1 on March 9, 2013, at 2:10 p.m. with complaints of passing blood clots rectally since 10:00 a.m., as well as back and abdominal pain.

Review of the initial ED nursing assessment revealed the patient's pain was 7/10 with 10 being the highest level of pain. Continued review of the nursing assessment revealed the patient stated the pain was aching and throbbing and was located in both lower quadrants of the abdomen. Further review of the nursing assessment revealed the pain did not radiate. Continued review of the nursing assessment revealed the patient's abdomen was tender to palpation in both right and left lower quadrants.

Review of the Physician Documentation from the ED revealed "...presents to ED via walk-in with complaints of abdominal pain, back pain. Symptoms/episode began/occurred acutely 4 hours ago. The symptoms do not radiate. Associated signs and symptoms: none..."

Review of the Certification of Medical Screening Examination revealed "...the patient's condition is such that the patient DOES HAVE an Emergency Medical Condition (EMC) requiring further emergency medical evaluation, treatment, and/or stabilization. The EMC was GI Bleed..." and was signed by the ED physician.

Review of laboratory studies completed on March 9, 2013, revealed a white blood count of 20.2 (normal 4.8 - 10.8); hemoglobin 14.4 (normal 11.7 - 16.1); hematocrit 41.0 (normal 35.0 - 47.0). Continued review of laboratory studies revealed a urinalysis was negative.

Review of a Computerized Tomography (CT) of the abdomen and pelvis revealed "...the bowel and mesentery are unremarkable with no evidence of obstruction..."

Review of discharge instructions given on March 9, 2013, at 5:38 p.m. revealed a diagnosis of sinusitis with discharge medications to include Toradol (Pain medication)10 mg (milligrams) 5 pills ordered to be taken orally once daily not to exceed 4 tablets in 24 hours and Zithromax 250 mg oral tablets 2 to be taken one time then one tablet daily for 4 days. Further review of the physician documentation revealed c/o (complained of) sinus pressure and on examination "...pressure in paranasal sinuses..." was hand written on the printed copy of the physician documentation form.

Medical record review from hospital #2 revealed the patient arrived on March 9, 2013, at 7:13 p.m. Continued medical record review revealed, on physical examination, the resident's abdomen to be protuberant, slightly distended, and tight with hypoactive bowel sounds. Continued review revealed a rectal examination was performed and stool was guiac positive (blood present in the stool). Further medical record review revealed the patient was admitted to facility #2 and underwent colonoscopy which demonstrated "...severe inflammation found in descending colon and transverse colon secondary to ischemic colitis..." Continued medical record review revealed the patient was admitted to hospital #2, treated and discharged home on March 13, 2012.

Review of the letter dated March 18, 2013, sent by patient #5 to facility #1, revealed the patient's personal physician had told physician #1 to transfer the patient to hospital #2, but since all diagnostic tests were normal physician #1 felt the patient could go home and prescribed an antibiotic for a sinus infection in case that was the cause of the high white blood cell count. Continued review of the patient's letter revealed the patient and spouse were on the way to their car (after being discharged from the ED at facility #1) when the bleeding started again so the patient came into the facility and used the restroom. Further review of the letter revealed the bottom of the toilet was filled with black clots and the rest of the bowl was dark red. Continued review revealed the patient's spouse went into the ED to tell them what was going on. Further review revealed one nurse started to get up but physician #1 said to stay and told the spouse if the patient wanted to come back to the ED for more blood tests the patient could do that or the spouse could take the patient to facility #2. Continued review of the letter revealed while en route to facility #2, the patient felt pressure building up in the back and asked a County Deputy to call an ambulance to transport the patient to facility #2 on March 9, 2013. Further review of the letter revealed the patient was admitted to facility #2 and remained there until March 13, 2013.

Interview with the Director of ED at hospital #1 on March 27, 2012, at 2:55 p.m., in the director's office, revealed the first time the Director was aware of a problem with patient #5 was when a letter from the patient dated March 18, 2013, was shared with the Director. Continued interview revealed if a nurse disagrees with a physician about care issues or discharge the nurse needs to speak with the physician. Continued interview revealed if that does not work the nurse can call the patient's personal physician and notify the house supervisor. Further interview revealed the nurse may contact the Administrator on Call who has access to the Chief of Staff.

Continued interview with the Director of ED revealed if a patient were to come to the ED passing clots the nurse ought to be very concerned. Continued interview revealed all nurses know they cannot tell a patient to go to a higher level of care.

Further interview with the Director of the ED revealed if a nurse was told a patient had passed blood and clots in a public bathroom outside the ED in hospital #1 it was an expectation the nurse would go to investigate. Continued interview with the Director of the ED revealed "...If someone requests assistance you are obligated to check it out..."

Interview with the Registered Nurse (RN) who was the patient's primary nurse in the ED of facility #1 on March 27, 2012, at 3:10 p.m., in the ED Director's office, revealed the nurse was unable to recall patient #5 either by description or by name. Continued interview revealed if the nurses didn't agree with the physician's discharge decision the nurse would ask the doctor why...made that particular decision and ask the physician if this had been discussed with the resident and family. Continued interview with RN #1 revealed if a patient was passing blood clots the nurse would observe vital signs or a decrease in blood pressure and increase in pulse, and would suggest to the physician the patient needed to be transferred to a higher level of care.

Interview with physician #1 who cared for the patient on March 9, 2013, confirmed physician #1 was the physician on duty at facility #1's ED on March 9, 2012. Continued interview with physician #1 revealed the physician was unable to recall the patient. After reviewing the patient's record, physician #1 stated "...I remember having to go back in the record because"...had some sinusitis and I ordered antibiotics. Someone asked why the patient was on antibiotics..." Further interview revealed physician #1 talked to the patient's personal physician who felt since the patient was stable (vital signs stable, no further bleeding) the patient could be discharged home. Continued interview with physician #1 revealed "...If I had known...had more bleeding before...left I would have brought...back. Physicians here do not do scopes (insertion of a flexible tube passed through the anus for endoscopic examination of the large bowel and distal small bowel) and if...had come back with bleeding I'm sure I would have done something, transferred...to hospital #2." Further interview with physician #1 confirmed there was no documentation in the medical record to indicate physician #1 spoke with the patient's personal physician.

Interview with the Director of Risk Management at facility #1 on March 28, 2012, at 8:45 a.m., in the conference room revealed the Director had taken the patient's letter very seriously. Continued interview revealed the Medical Director of the ED reviewed the patient's record who stated more treatment should have been done. Further interview revealed the radiologist over-read the CT scan and agreed with the findings.

Interview with the Director of the ED at facility #1 on March 28, 2013, at 10:50 a.m., in the Director's office, revealed as soon as the Director heard of the incident, the Director conducted an inservice for all staff to reiterate they cannot be told by a physician not to check on a patient. Continued interview revealed the Director shared the letter from the patient with the Medical Director of the ED. Further interview revealed none of the staff can remember the incident on March 9, 2013, (when patient #5 had gone into the restroom and passed bloody stool) so no one knows who physician #1 was speaking to when telling the nurse not to check on the patient because the patient was discharged.

Interview with the Medical Director of the ED at facility #1 on March 28, 2013, at 11:00 a.m., in the director's office, revealed the protocol for assessing a patient complaining of abdominal pain and passing clots was to order blood work: complete blood count to assess hemoglobin and hematocrit which may have decreased from the bleeding; complete metabolic panel to assess electrolytes; rectal examination to determine evidence of bleeding; guaiac of stool to determine if there is blood in the stool; and a CT scan of the abdomen. Further interview with the Medical Director revealed when the physician was told the patient had passed blood and clots in the bathroom the physician should have had the patient sign back into the ED for re-evaluation. Continued interview with the Medical Director revealed "...the most medically sound action would be to re-evaluate the patient..." Further interview with the Medical Director, who re-reviewed the medical record at the same time, confirmed there was no documentation of a rectal examination and "...this would be part of an examination for GI bleed..."Further interview with the Medical Director confirmed there was no stool hemocult (test for blood in the stool) ordered - the staff collects the specimen but the laboratory interprets it. Further interview with the Medical Director revealed a physician's order is required for the stool interpretation and confirmed there was no order in the medical record. Continued interview with the Medical Director revealed there was no documentation in the patient's record by the physician of a patient history related to sinusitis; no documentation in the patient examination of sinusitis or complaints of sinus problems; and "...no pathway to get to sinusitis..." Further interview with the Medical Director revealed abdominal pain was not documented as a final diagnosis and "...nothing was documented at discharge to address the initial complaint..."