The patient was discharged from the ED. She had been in the ED for several hours overnight, and therefore her family members had gone home with the intention of picking her up once she was discharged.
After being discharge, she was sitting in the lobby of the ED, waiting for a ride home. There were family members of other patients sitting in the waiting room, and one of them came up to the triage desk to get the nurse’s attention.
The patient had collapsed and did not appear to be breathing.
The patient was immediately rushed back into the ED. She did not have a pulse and CPR was started. A new ED doctor took over her care.
The code sheet is shown below:
The physician’s note is shown below:
The note was not signed by the ED physician until the following day. He went back to the note and added an extra statement.
The suggestion that the patient choked on food opens up the possibility that the her own actions caused the bad outcome. However, the manner in which this note was added raised suspicions that the physician was entering false information into the chart to cover for his partner.
The patient survived the hospital admission, but unfortunately was left with a devastating anoxic brain injury. She is unable to communicate or care for herself, and requires 24/7 nursing care.
A lawsuit was filed by the patient’s family members. Their initial claims are listed on the next page, alleging both EMTALA violations and medical negligence.