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Based on record review and interviews, the facility failed to ensure that staff working in the emergency department had current EMTALA (Emergency Medical Treatment & Labor Act) training for 7 (#13, #14, #15, #16, #17, #18, and #19) of 15 staff members.


A review of the training log provided by the education department revealed that 7 (#13, #14, #15, #16, #17, #18, and #19) of 15 nursing staff working in the emergency room did not have the EMTALA training within the last year.

Staff # 13 last EMTALA training was 01/25/2022

Staff # 14 last EMTALA training was 03/20/2021

Staff # 15 last EMTALA training was 03/27/2021

Staff # 16 last EMTALA training was 02/09/2021

Staff # 17 last EMTALA training was 02/22/2021

Staff # 18 last EMTALA training was 03/15/2022

Staff # 19 last EMTALA training was 04/10/2021

An interview with Staff #8 on 11/06/2023 at approximately 11:00 AM confirmed that EMTALA training was required on an annual basis.

A review of the facility policy titled, "Orientation, Training, & Education of Staff - Competency Plan for 2023" revealed the following:

"Mandatory Annual Training for all employees: Annually, all employees will be required to complete a self-study educational program via on-line education modules. These topics include requirements from The Joint Commission, CMS, Risk Management, Infection Control, OSHA, etc. The specific topics covered by the training modules set by Corporate are:

FOR NON-CLINICAL EMPLOYEES: (as appropriate to job description)
1. Active Shooter Response in Healthcare Setting
2. Acute Coronary Syndrome
3. Anti-Discrimination Training
4. Code of Conduct
5. Early Heart Attack Care (EHAC)
6. EMTALA
7. Information Security Awareness
8. MRI Safety
9. National Patient Safety Goals
10. Patient Abuse/ Assault/ Neglect
11. Preventing Patient Falls
12. Radiation Safety
13. Rapid Regulatory Compliance Non-Clinical I, including, Corporate Compliance & Ethics, HIPAA, Sexual Harassment, Patient Rights, Confidentiality, Participation in Treatment Decisions, Respect, Safety and nondiscrimination, Patient Visitation Rights, Grievances
14. Rapid Regulatory Compliance Non-Clinical 11, including, General Safety, Fire Safety, Electrical Safety, Ergonomics, Back Safety, slips, Trips, & Falls, Hazard Communication, Security & Workplace Violence, Reporting Incidents, Emergency Preparedness, Infection Control, Health¿care Associated Infection, Hand Hygiene, Antibiotic Resistance, Airborne Pathogens, Bloodborne Pathogens, Personal Responsibility
15. Safety Incident Management

EMTALA Training Course and Test is required for the following employees:

ED Employees
ED Physicians
OB Department Staff
ED Registration Clerks/Phone Operators
EMS Personnel
Security Personnel
All Administrative Officers
House Supervisors"

An interview with Staff #4 on 11/06/2023 at approximately 11:00 AM confirmed that EMTALA training was required on an annual basis and staff #13, #14, #15, #16, #17, #18, and #19 had not had EMTALA training within the last year.

Based on observation and interview, the facility failed to monitor and provide a sanitary environment to minimize the transmission of infectious agents within the emergency room of the hospital that were observed.

These findings had the likelihood to cause harm by increasing the risk of infection to all patients receiving care at the facility.


During a tour of the facility on 11/06/2023 at 3:00 PM with Staff #4, #5 and #8 the following infection control issues were observed and acknowledged:

Emergency Department:

Triage room

The chair in the triage room had a large amount of cushion missing on the arms. The yellow discolored sponge cushion was showing on both arms. There was no way that staff could clean the chair.


Exam room #3

Observed broke off knobs on the cabinet drawers. The surveyor was unable to open the cabinets; the housekeeping staff took a flat edge tool to open the cabinet doors. There were numerous scratches in the paint of the cabinets and large areas of plaster missing from the wall.
(This was cited on the survey from 1/18/2023.)

Patient Bathroom (Located outside exam #12)

The bathroom floor was dirty with black substance in the corners of the room. The top side edge of the tile around the walls of the bathroom was brown with dust particles and debris. The emergency pull cord had the tip pulled off and if the patient tried to pull the cord, the cord would just pull through the hand of the patient.


Exam room #12

Observed a large piece of equipment that was used to create a negative pressure room in exam room #12. The ducting was taped with a large amount of black tape to a vent in the ceiling.
(This was cited on the survey from 1/18/2023.)

The was a small black portable 2-drawer cabinet in the room that had dust and dirt on the crease of the cabinet. Also, white spillage was running down the side of the cabinet.

There was a large yellow rusted "H" (size of the cylinder) cylinder observed sitting in the corner of exam room #12.

Mutiple dead bugs were observed in two of ceiling light fixture outside of exam room #12.

Exam room #12 was cluttered and had an unclean appearance.

(This was cited on the survey from 1/18/2023.)


Supply Storage Area (located by exam room #8)

The floor was covered in lint, trash particles, dust, and dirt around all 3 walls of the storage closet.

There were 2 bedside commode chairs wrapped with plastic stacked on top of themselves, which per staff #4 meant the equipment was clean. There was a brown substance smeared down the leg of the commode chair. Also, stored in the closet was a portable "InTouch Health" video monitor. This equipment was used for telehealth services for Neurology. There was no way to determine if the monitor was clean or dirty.


Patient Nourishment Room

The cabinet below the sink had loose handles that were falling from the cabinet doors. Holes from missing screws and chipped paint were exposing the wooden surface. There was a coffee pot on top of the counter. The drawer directly beneath the coffeepot stored "Community Coffee" packets used to make coffee. Inside the drawer was a moderate amount of loose coffee grounds. When opening the drawer, observed a large dried brown liquid spill. Also below the drawer was a cabinet that had a dried brown liquid spill on the door surface.
(This was cited on the survey from 1/18/2023.)

The drawer directly beneath the refrigerator stores crackers for patients' use. Inside the drawer was a large amount of broken cracker crumbs. Stored in the cabinet beneath the refrigerator was a plastic container of 10 Ounces of "Thick-It". This product is used to thicken a patient's liquids to aid in swallowing. There was no open date on the container. (This was cited on the survey from 1/18/2023.)


ER Hallways

Multiple, blue-painted doorframes throughout the ER Department were missing paint and exposing the bare metal surface. Metal cannot be sanitized to prevent the spread of infectious diseases. Along the hallways, attached to the walls, were wooden hand rails painted blue. The wood was chipped and missing paint exposing the wooden surface beneath. The porous surface cannot be sanitized to prevent the spread of infectious diseases.
(This was cited on the survey from 1/18/2023.)


An interview was conducted with Staff #4 on 11/06/2023 at 3:30 PM and confirmed the infection control issues that were observed on the tour. Staff #4 acknowledged that some of the issues observed on tour were seen on the previous survey from 01/18/2023.

Based on record review and interview, the facility's emergency department physician #11 failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services.

Findings include:

The patient had been in the local Emergency room 8 times since the beginning of the year 2023.
The dates of service and diagnosis are as follows:

1-01-2023 -Cough
1-23-2023 -Cystitis
2-25-2023 -Fever
3-12-2023 -Nausea/vomiting
3-24-2023 -CT scan (Diagnostic imaging)
4-12-2023 -Nausea/vomiting
9-11-2023 -Nausea/vomiting
9-12-2023 -Nausea/vomiting

Patient #1 was born at the local Hospital on 7-11-2022


Patient # 1 was a 14-month-old female with a Wilms tumor on the right kidney and had a resection of the kidney on 3/27/2023 at a children's hospital in Dallas. The patient was discharged on 4/1/2023 after the surgery from the children's hospital. The patient had to undergo 19 weeks of Chemotherapy which concluded on August 8, 2023.


A review of the medical record for the date of service on 9/11/2023 at 11:50 AM revealed Patient # 1 was in the emergency room for nausea and vomiting.

Vital signs:

11:57 AM Pulse 132, Respiratory rate 32, Temperature 97.3 (No blood pressure documented)
Pulse Oxygen 100%
1:53 PM B/P 98/65 pulse 120, Pulse Oxygen 97%
2:00 PM B/P 103/62 pulse 106, Pulse Oxygen 98%
3:00 PM B/P 98/56 pulse 125, Pulse Oxygen 98% Temperature 99.3
4:00 PM B/P 114/75 pulse 129 Pulse Oxygen 97%
4:47 PM B/P 104/64 pulse 123, respiratory rate 20 temperature 98.3 Pulse Oxygen 97%

A review of Physician #11 notes revealed the following:

"2:29 PM The patient presents to the emergency department with nausea and vomiting.
Onset: The symptoms/episode began/occurred acutely.
Possible causes: unknown. The symptoms are aggravated by nothing. The symptoms are alleviated by nothing.
Associated signs and symptoms: The patient has no apparent associated signs or symptoms. Severity of symptoms: At their worst, the symptoms were moderate this morning, in the emergency department the symptoms are unchanged. The patient has not experienced similar symptoms in the past. The patient has not recently seen a physician. The patient recently finished chemotherapy for renal carcinoma.

Abdomen/GI: Inspection: abdomen appears normal, Bowel sounds: normal, in all quadrants, Palpation: abdomen is soft and non-tender, in all quadrants, mass, is not appreciated, rebound tenderness, voluntary guarding, is not appreciated, involuntary guarding, is not appreciated, no appreciated organomegaly."


A review of patient #1's labs dated 09/11/2023 revealed the following abnormalities:

"Glucose-109
BUN- 20
Create- 0.25
WBC- 13.2
Neut%- 81
Lymp%- 15
Low Ketones in the urine- 40
Protein in the urine- 30"

A review of Physician #11 notes showed no documentation that the elevated WBC, BUN, or ketones in the urine were addressed.

A review of the Chest x-ray performed at the 09/11/2023 revealed the following:

"Right chest wall port tip overlying the SVC. Normal heart size.
No pulmonary vascular congestion. No pneumothorax or pleural effusion. The lungs are clear. No fracture. Surgical clips overlying the midline abdomen.
IMPRESSION: No acute cardiopulmonary abnormality."

Patient #1 had undergone major abdominal surgery for a Wilms tumor on the right kidney and had a resection of the kidney. There were no tests ordered for possible bowel obstruction, bowel ischemia, or abscess which could have addressed the reason for nausea and vomiting.

Patient #1 had the likelihood of having an emergency medical condition of sepsis, which could have led to septic shock, multiorgan failure, and death.

A review of the nurse's notes revealed that the mother reported the child had only 1 wet diaper before arrival and was lethargic. There was no documentation from the registered nurse or the physician addressing hypovolemia/dehydration/sepsis. Also, there was no pediatric consult from the local pediatrician or consult for a transfer back to the Children's Hospital where the child had previously received care. The medical chart did not indicate that the child was tolerating oral fluids before discharge.


A review of the nurse's discharge note revealed Patient #1 was discharged home at 4:47 PM. "Discharge Assessment: Patient lethargic. Patient appropriate for age. Discontinued IV intact, bleeding controlled, pressure dressing applied, No redness/swelling at site.
4:57 Patient left the ED (emergency department)."

Patient #1 was discharged lethargic to the mother with instructions to return if conditions worsen.

An interview with Staff #6 on 11/06/2022 at 4:00 PM acknowledged that emergency physician #11 failed to provide an appropriate medical screening examination.

Based on record review and interview, the facility's emergency department physician #10 failed to determine if an emergency medical condition existed and failed to stabilize Patient #1's condition before transferring to a children's hospital.

A review of the medical record for patient #1 revealed the patient arrived at 1:42 AM on 09/12/2023 at the local emergency room with her parents with continued vomiting. This visit was approximately 9 hours after patient #1 was discharged on 9/11/2023 emergency room visit for vomiting.

A review of Physician #10's notes revealed the following:

"2:18 AM This 14-month-old White Female presents to ED via walk-in with complaints of Vomiting.

The patient is a 14-month-old female with a history of Wilms tumor status post resection who presents to the emergency department for nausea, vomiting, and lethargy. Mom states the child has been vomiting for a couple of days and they were seen here in the emergency department earlier today and given fluids. She states that she maxed out on her Zofran and so brought her here. She states that her daughter is pale and extremely lethargic. She states that she was going to drive her daughter to "Facility-A" in Dallas where she gets her care however she did not think that she could make it. She states that her daughter just finished 20 weeks of chemo and that was last finished on August 8th. She will have surgery again next month.

Abdomen/GI: Positive for vomiting.
Head/Face: Normocephalic, atraumatic.
Eyes: Pupils equal round and reactive to light, extra-ocular motions intact. Lids and lashes are normal. Conjunctiva and sclera are non-icteric and not injected. Periorbital areas with no swelling, redness, or edema.
ENT: Nares patent. No nasal discharge. Tympanic membranes are normal and external auditory canals are clear. Oropharynx with no redness, swelling, or masses, exudates, or evidence of obstruction, uvula midline. Mucous membranes are moist.
Neck: Trachea midline and no cervical lymphadenopathy. Supple, full range of motion without nuchal rigidity, or vertebral point tenderness. No Meningismus. Chest/axilla: Normal symmetrical motion. No tenderness. No axillary masses or tenderness.
Cardiovascular: Regular rate and rhythm with a normal S1 and S2. Skin: Warm and dry with excellent turgor. No rashes are appreciated.
MS/ Extremity: Pulses equal, no cyanosis. Neurovascular intact. Full, normal range of motion.
Neuro: Awake and alert, interacting appropriately. Moving all extremities equally. Sensory grossly intact.
Constitutional: The patient appears lethargic, obviously ill, pale. Respiratory: the patient does not display signs of respiratory distress, Respirations: tachypnea, Breath sounds: are normal, and clear throughout.
Abdomen/GI: Inspection: abdomen appears normal, Bowel sounds: normal, Palpation: abdomen is soft and non-tender, in all quadrants."

Further review of the Emergency room notes revealed that the only lab drawn was a BMP (basic metabolic panel). This was the only test performed on the 09/12/2023 emergency room visit.

Patient #1's primary physician was not notified. A review of the emergency on-call log for 09/12/2023 revealed there was a pediatrician on call. The pediatrician was not notified.

A review of the lab report revealed the following were documented as abnormal.

"Potassium- 5.7
BUN- 40
Creatine-1.02
Bun/Creatine- 43
Osmoc- 296"

A review of Physician #10's notes showed no documentation that the elevated Potassium and BUN were addressed.


The medical record revealed that these were the only vital signs recorded during the visit.

"Vital signs:
1:46 AM P 181 R 30 Temp 97.2 pulse OX 96%
2:42 AM B/P 69/34 P 158 100% 2liter N/C
3:05 AM B/P 70/40 P 189 100% 2liter N/C
3:16 AM B/P 68/38 P 180 100% 2liter N/C
3:46 AM B/P 73/42 P 194 100% 2liter N/C
4:06 AM B/P 80/47 P 180 100% 2liter N/C
4:25 AM B/P 87/37 P 188 100% 2liter N/C
4:30 AM B/P 88/43 P 171 100% 2liter N/C"

A review of the vital sign log revealed there was no blood pressure taken on admission and the respiratory rate was only taken on admission.

A review of Physician #10's notes showed no documentation that the elevated heart rate and low blood pressure were addressed. Patient #1 showed signs and symptoms of septic shock as evidenced by the low blood pressure and elevated heart rates.


The medical record revealed that Physician #10 called the children's hospital where patient #1 had received treatment in the past and had undergone major surgery.

A review of the "Telephone Encounter" that transpired on 9/12/2023 at 2:44 AM with the physician at the children's hospital revealed the following:

"... 14-month w/ hx of Wilms, currently done with chemotherapy was seen on 9/11/2023 for vomiting unable to control w/ home Zofran, got 20 ml/kg bolus, UA negative, chest x-ray negative. Reportedly has a blood culture from that time. Got vomiting under control so was d/c home.

Approximately 70 min ago now (2:50) mom brought her in appearing-pale, tachycardic, and "lethargic". Satting 90% on Room air so put on 2L NC. Initial heart rate 180's, BP 69/34, "clamped down". HR 150's after 20 ml/kg bolus. Small line, unable to get further access. No viral symptoms, no sick contacts. Repeat BP 70/42. HR 194 w/ crying. Cap refill (less than <5 sec but couldn't specify if greater than 2-3). Didn't know if there was a port in place.

Discussed:

Emergently - repeat fluid bolus to improve hypotension. Pt. has shock, possibly hypovolemic but most concerning for sepsis given severe presentation. Unable to draw blood cultures at this time. As per sepsis guidelines, would receive at least 60 ml/kg rescue to help manage the shock, followed by pressors.

Discussed with attending Dr. - if concerned about the need for sepsis and still unable to draw blood cultures/access port and with worsening pressures/tachycardia, please give abx (antibiotics) w/o cultures.

If starting to stabilize, can consider holding off at this time. Consider 2nd access such as IO if needed to help with fluid resuscitation efforts.
Most recent labs: Hg - 11.5, WBC 13.2 (similar to ours 7 days ago outside of the elevation in WBC).

@3:40am - called for an update. Pt overall similar, still lethargic w/ BP 70s systolic. Receiving continued fluid rescue, unable to access port so no abx right now. For acute decompensation, need to consider pressors and abx after attempting IO or other site of access. Our FW aircraft pilots are not available, and our helicopter team cannot fly out right now. Will monitor the situation but OSH trying to arrange transport for her via flight."


A review of the medical record revealed patient #1 had a 24-gauge intravenous catheter in place receiving 20 ml/kg of normal saline. The chart noted the patient had a Port-O-Cath (central catheter) but was not used as second access. There was no documentation that the physician had followed the recommendations from the children's hospital. There was no documentation of repeat fluid bolus to improve hypotension, and sepsis guidelines were not followed because the patient should have received at least 60 ml/kg rescue to help manage the shock, followed by pressors. Also, there was no documentation that the facility staff attempted to use Port-O-Cath to draw blood cultures, and with worsening pressures/tachycardia antibiotics should have been administered.


A review of patient #1 medical record for the date of service on 09/12/2023 at 6:05 AM at Children's Hospital revealed the following:

"History obtained from Other: Due to the inability of the patient to provide an adequate and complete history, I have obtained an additional, relevant history from the mother, who is the caregiver of the patient.
A 14-month-old female with a history of Wilms tumor status post-chemo presents from an outside hospital for concern for fever, vomiting, and lethargy. On arrival, the patient appears lethargic, pale, tachycardic, and hypotensive. Started resuscitation. Noted to have soft central pulses. Central line accessed. Labs sent. Given fluids and placed on ephedrine drip. EKG changes were noted, with peaked T waves, given calcium.

The patient then became less responsive and had large dark brown emesis. The decision was made to call anesthesia to the bedside for intubation. Given significant hemodynamic instability, preparation for possible arrest. Placed on Zoll. Increased ephedrine drip. Faint pulses but adequately seen on Point of Care Ultrasound (POCUS).

Cardiopulmonary arrest post-intubation.
Started CPR/ephedrine POCUS at the bedside for cardiac activity during pulse checks Given multiple rounds of epi, bicarb, and calcium. PICU paged for possible transition to ECMO CPR. No return of spontaneous circulation after 40 minutes Time of death called at 657."


A review of the completed autopsy report revealed the following:

"Based on the gross findings, the following preliminary conclusions are drawn:
Autopsy examination revealed diffuse small bowel ischemia with subsequent sepsis and cardiopulmonary changes. The small bowel was diffusely dusky, congested, and hemorrhagic with a tight adhesion of loops of proximal jejunum and underlying severe congestion of the vasculature within the small bowel mesentery. The peritoneal cavity contained 100 cc of serosanguinous fluid. Autopsy blood and tissue (lung) cultures show abundant growth of Escherichia coli and Lactobacillus sp., the tissue culture possibly representing bacterial growth within blood vessels (pending histologic examination of the lungs). The chest showed more subtle changes of cardiopulmonary compromise. Bilateral pleural effusions were present as well as a small pericardium effusion. The lungs were heavy and congested. Green-brown, bilious material was found in the esophagus up to the proximal aspect as well as in the distal trachea suggestive of aspiration.

The abdomen also showed changes consistent with the patient's clinical history of Wilms tumor. Post-surgical changes included surgical absence of the right kidney and non-obstructive bowel adhesions involving the ascending colon. Enlarged mesenteric lymph nodes were noted (pending histologic examination). The radiologically identified possible metastatic nodule was identified in the right lower lung base."

An interview with Staff #6 on 11/06/2022 at 4:00 PM acknowledged that emergency physician #10 failed to determine if an emergency medical condition existed and failed to stabilize Patient #1's condition before transferring to a children's hospital.

Based on record review and interviews, the facility staff failed to meet the following requirements of an appropriate transfer for 4 (#1, #8, #9, and #10) of 4 Memorandum of Transfer (MOT) who had acute emergency medical conditions and were not completed before transfer. Also, the time of the risks and benefits that were explained to the family did not closely match the date and time of the actual transfer. In addition, the reason for the transfer was not documented in the Memorandum of Transfer. The facility failed to provide medical treatment within its capability and capacity that minimized the risks to the individual's health.

Findings include:

A review of the transfer log for September 2023 for children under the age of 5 revealed that 4 (#1, #8, #9, and #10) of 4 Memorandum of Transfer forms were not completed before the children were transferred to the transferring facility. Memorandum of Transfer forms were reviewed with Staff #4 and #6.

Patient #1

The date of service was 9/12/2023 with a diagnosis of intractable nausea and vomiting, dehydration, and immunocompromised. The reason for the transfer was a higher level of care. There was no documentation as to who the nursing report was given to, the date and time, and the nurse's signature were all left blank. The risk and benefits were signed by physician #10 at 3:30 AM the patient did not leave the emergency room until 4:55 AM. The last vital signs documented on the MOT were at 3:30 AM. The patient left the emergency room at 4:55 AM by helicopter.


Patient #8

The date of service was 9/22/2023 with a diagnosis of dehydration, vomiting, and decreased urine output. The reason for the transfer was not documented. There were no vital signs documented on the MOT. There was no documentation as to who the nursing report was given to, the date and time, and the nurse's signature were all left blank. The risk and benefits were signed by physician #11 at 7:20 PM the patient did not leave the emergency room until 9:02 PM. The patient left the emergency room at 9:02 PM by ground ambulance.

Patient #9

The date of service was 9/28/2023 with a diagnosis of seizure and respiratory failure. The reason for the transfer was a higher level of care and specialty services not available. Vital signs for the patient were not documented on the MOT. There was no documentation as to who the nursing report was given to, the date and time, and the nurse's signature were left blank. The risks and benefits were signed by physician #12, but there was no time documented as to when the risks and benefits were explained to the family. The patient left the emergency room at 2:13 PM by helicopter.


Patient #10

The date of service was 9/26/2023 with a diagnosis of recurring seizures. The reason for the transfer was specialty services were not available. There was no documentation as to who the nursing report was given to, the date and time, and the nurse's signature were all left blank. The risk and benefits were signed by physician #11 at 3:10 PM the patient did not leave the emergency room until 4:32 PM. The last vital signs documented on the MOT were at 3:00 PM. The patient left the emergency room at 4:32 PM by ground ambulance.


An interview with Staff #4 on 11/06/2023 at 3:00 PM was conducted throughout viewing the Memorandum of Transfer (MOT) and was asked to provide copies of the incomplete MOT. Staff #4 acknowledged the missing information and provided copies of the Memorandum of Transfer (MOT) forms.