Court case highlights nurses' duty to follow EMTALA




Helping a troubled patient

If you are an emergency nurse, you practice within the requirements of the Emergency Medical Treatment and Active Labor Act. However, the nurse in the following case made a patient care decision that may have violated EMTALA. (Munoz v. Watsonville Community Hospital, Case No. 15-cv-00932-BLF, United States District Court Northern District of California San Jose Division, Jan. 25, 2017)

KH, a female, underwent gastric bypass surgery and was discharged without complications. About 15 months later, she had intermittent episodes of severe abdominal pain and went to an emergency department. The emergency room physician examined her and diagnosed KH with intermittent bowel obstruction. She was treated with IV medication and hydration. The obstruction seemed to have resolved at the time and she was discharged.

Three months later, KH went to another ED complaining of abdominal pain. This ED had no records from her prior visits to the former ED and she was not able to communicate her history fully due to her limited ability to speak English. Laboratory results were normal, except for “very mild hypokalemia” and mild dehydration. An X-ray of the abdomen indicated a significant amount of stool with a few air-fluid levels. The ED physician gave KH an opioid analgesic, and when her pain level decreased to 0 on a scale of 1-10, she was discharged with a prescription for a laxative.

Later on the same day, she returned to this same emergency department because the pain had resumed. The physician was aware of her history, determined that her pain level was 10 on a scale of 1 to 10, and found her condition to be a “certified medical emergency.” After treating her with Ativan, Haldol and a soap suds enema, the ED physician discharged the patient. The discharge nursing note indicated the patient had a pain level of 8 out of 10 at the time of discharge.

Upon returning to her home, KH’s condition worsened. She went into cardiac arrest and was taken back to the ED from which she was discharged. She was resuscitated but died the next day after another cardiac arrest. The cause of death was peritonitis and septic shock due to an internal hernia.

The rationale behind the lawsuit

KH’s former husband and father of her minor child filed a lawsuit alleging violations of EMTALA. The hospital in which the ED was located filed a Motion to Dismiss KH’s complaint.

The court stated the purpose of EMTALA is to provide an appropriate medical screening examination within the capability of the facility, and if an emergency medical condition exists, it must provide treatment to stabilize the condition. EMTALA also includes conditions under which a patient may be transferred.

After reviewing the evidence in KH’s case, the court held there was an appropriate medical screening and therefore granted the first part of the hospital’s Motion to Dismiss. The court did not grant the hospital’s second part of its Motion, however. It held that discharging KH with a pain level of 8 out of 10 violated the hospital’s duty to stabilize KH and it also failed to transfer her to a facility for her high level of pain, which was the identified emergency medical condition. The court clearly pointed out that there was no duty to treat an undiagnosed condition (the hernia).

Due to the court’s rulings, the case continues in trial court and has not yet been concluded. However, the case highlights several important duties of an ED nurse.

Regardless of a physician order to discharge a patient from an ED, an ED nurse has the legal and ethical obligation to question such an order when the patient’s condition warrants it. In this case, the severe pain level was simply documented by the nurse. The nurse apparently did not question the ED physician about the order or notify her supervisor about the questionable order or take any other action to prevent the discharge. As a result, the hospital may have violated EMTALA.

More importantly, the nurse appears not to have fulfilled her duties to KH grounded in standards of practice, the state nurse practice act and the Code of Ethics for Nurses with Interpretive Statements. At the very least, the patient’s condition warranted compliance with these obligations.

EMTALA also requires specific care, stabilization, and transfer requirements for women in active labor who present in an ED.

EDITOR’S NOTE:

Nancy Brent’s posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.

Click here for a wide range of emergency care-related continuing education modules.


About the author
Nancy J. Brent, MS, JD, RN

Nancy J. Brent, MS, JD, RN 

Nancy J. Brent, MS, JD, RN, Nurse.com's legal information columnist, received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation, consultation and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues in nursing and healthcare delivery across the country and has published extensively in the area of law and nursing practice. She brings more than 30 years of experience to her role of legal information columnist. To ask Nancy a question, email BrentsLaw@nurse.com.

14 responses to “Court case highlights nurses’ duty to follow EMTALA”

  1. This patient (KH) was seen by 3 different physicians but it’s the nurse who violated EMTALA? What were her pain levels at discharge the other 2-3 times? All members of the care team are accountable.

    • Good point. It seems the nurse always gets the final blame. Something wrong with a Doc that doesn’t ask his patient how they are feeling before discharge, and chart that He did it

    • As a 40+ year RN, it seems to me that your comment is a ‘victim’ response so often heard from a Nurse: “it’s not my fault”, or “the (Doctor, CNA, other Nurse) didn’t do what they were supposed to do”, or “the Nurse is being treated unfairly”. In this case, what the other Physicians and Nurses did or didn’t do doesn’t change the fact that this ED Nurse discharged a patient with a pain score of 8/10. I wonder if this Nurse missed or ignored other objective or subjective signs that indicated the patient wasn’t ready for discharge? Nurse-Attorney Brent wrote this article to instruct and help another Nurse practice safely and legally, but I’m afraid you may have missed the benefit of the lesson by being so defensive. Please remember that as a licensed professional, the State grants you the privilege to practice and in return you promise to practice to a set of standards and you are responsible for your own actions.

    • Looking back over my 38 years as a nurse I can recall dozens of events when I questioned a Doctor or made a suggestion. I was promptly put in my place. I’M THE DOCTOR, accompanied by a glare and silent challenge. I went behind the doctors back and intervened, actions which saved the patients lives or preserved following the law or upholding policy but earned me a reputation as a trouble maker. Unfortunately Hospital administrations can be just as volatile. There exists a very tenuous relationship between Doctors and nurses and employers. Ocasionally it is possible to establish a level of mutual trust and cooperation and respect. What a blessing to work in that rare environment. My professional policy and advice is to know and do the right thing. Establish a reputation for being a straight arrow. Then let the chips fall where they may. Keep detailed notes, make copies if you suspect record tampering. Be sure to have witnesses i.e. discuss vital signs and details with your cohorts and unit manager. Ask if they have seen or dealt with a similar situation. I carry a voice activated tape recorder, it has helped several times. If you find yourself in a situation do NOT hesitate to go up the ladder. If your hospital admin does not support you, call a state investigator, the sooner the better. It will mean that you will be job hunting, Non Retaliation clauses are WORTHLESS. I took down 4 levels of administration and retired early. I can truly say that I wad a patient advocate and consumate professional from start to finish. God bless those of you who are still in the trenches. In some ways I miss the action of the front lines. I am now a Certified Legal Nurse Consultant and use my years of experience and expertise as a patient or victims advocate fighting for damages inadvertently, carelessly or hurriedly inflicted by a well meaning but over extended health care system. We must all be patient advocates, to do that well we must also be advocates of our profession. Be alert, educated and vigilant.Stand your ground, do not allow yourself or your integrity to be compromised by short staffing issues. Remember, document, document document. Every day I begin with a fresh 2x4in spiral notebook. I write everything down. Observations, questions, phone calls, interuptions, critical values, who said or did anything. Coworkers joked but Just seeing me writting notes seemed to make those around me more careful. I was always willing to share my notes and used them to make sure I followed up on tasks that may have been interrupted. Occasionally I ave had coworkers read, cofirm for accuracy and cosign the notes that I thought I might submit as evidence when needed. Of course I am careful to use only initials to protect patient confidentiality.
      Good luck to you all. if you have questions or need advice I would welcome helping you.

      • I used to keep a notebook with my notes, etc. many years ago until one day I was asked to turn everything over to management because it was a HIPPA violation to keep that kind of information for possible future use. Actually I was keeping my notes so that if I had the patient again and did not get all the information, I would still have my notes to go over.

  2. I’ve been in this situation before; I had a patient who was a passenger in an MVC, with headache. Monitored her closely for increasing headache. She was able to answer the Doctors questions and he ordered a discharge, mainly because we were so busy that he was in a hurry to see other patients. I refused to discharge, and gave my neuro exams as the reason. She was continuing to change and becoming confused. The doctor and I argued, and the EMS staff backed me stating that the patients condition was changing and they could see it. He ordered another nurse to discharge the patient while I was checking on another. Her stretcher was removed from the room and placed in the hallway with her on it. EMS found me and told me what was going on. I came out and re-assessed the patient.
    Found the doctor and requested a head CT, and told him she would not be discharged otherwise. After several arguments at the nurses station, I held my ground, he agreed to the head CT, and told me he would write me up after. The head CT showed a significant head bleed and the radiologist called the doctor immediately. The patient was flown out; and at the end of the evening the doctor thanked me.
    You sometimes have to be the unpopular nurse with the doctors, and be the patient advocate always.

  3. Did the discharging nurse communicated to the physician at the time if discharge that the pain level was 8 out 10?

  4. Nurses cannot prescribe pain medications. The doctor always visits the patient before discharge and would have also been aware of the pain level.

  5. My husband died in 1998 because I questioned his doctors care. My husband was having cardiac symptoms and I wanted a cardiac referrel and testing. My late husband told his physician that I was a Critical Care Nurse…as a result my husband did not get even a 12 Lead EKG in any of the 22 visits in 2 years even though my husband was having epigastric pain, syncopal episodes, and diaphoretic episodes. Believe me, that physician taught me a very valuable lesson. DO NOT QUESTION THE DOCTOR!!!So for those of you who are blaming the nurse because the DOCTOR discharged the patient…you have never worked or been at the bedside!!! He even told my late husband that I was “over-reacting” and does not have the credentials.

  6. My husband died in 1998 because I questioned his doctors care. My husband was having cardiac symptoms and I wanted a cardiac referrel and testing. My late husband told his physician that I was a Critical Care Nurse…as a result my husband did not get even a 12 Lead EKG in any of the 22 visits in 2 years even though my husband was having epigastric pain, syncopal episodes, and diaphoretic episodes. Believe me, that physician taught me a very valuable lesson. DO NOT QUESTION THE DOCTOR!!!So for those of you who are blaming the nurse because the DOCTOR discharged the patient…you have never worked or been at the bedside!!! He even told my late husband that I was “over-reacting” and does not have the credentials.

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