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Based on hospital policy, emergency department central log, video review, interview and record review, the hospital failed to provide an appropriate medical screening examination and further medical examination and treatment to stabilize the emergency medical condition for 1 of 20 sampled patients who came to the emergency department, (Patient #1).

Findings:

Refer to A2406 and A2407.

Based on hospital policy, emergency department central log, video review, interview and record review, the hospital failed to provide an appropriate medical screening examination for 1 of 20 sampled patients who came to the emergency department, (Patient #1).

Findings:

NURSE'S NOTES

On 6/16/21 at 8:10 PM, an Emergency Department (ED) Triage nurse's note read, "Pt (patient) c/o (complains of) abd (abdominal) pain with n/v (nausea and vomiting) X (times) 3 today. Per mom patient is autistic and is afraid to have a BM (bowel movement), sts (states) that they are seeing PCP (Primary Care Provider) about this and have abd US (ultrasound) scheduled. Pt awake, alert and oriented. Respirations equal and unlabored."

On 6/16/21 at 8:16 PM, the patient was triaged at a level of "3". Per hospital policy "Patient Acuity and Nursing Assessment in the Emergency Department", a level III means: "Does not require immediate or prompt medical attention but care involves multiple hospital resources."

On 6/16/21 at 8:37 PM, the Heart Rate only was taken, and was 80.

On 6/16/21 at 8:43 PM, a Glasgow Coma Scale score was documented by a Registered Nurse (RN). The results were: Best eye response: spontaneous. Best verbal response: oriented. Best Motor response: follows commands. Glasgow Coma Scale score: 15.

On 6/16/21 at 8:44 PM, triage notes reflected Vital Signs as: Heart Rate 180; Respiratory Rate 17; Blood Pressure 140/114; Oxygen Saturation 95%.

On 6/17/21 at 12:07 AM, a paramedic recorded Vital Signs: Temperature 98.6 (degrees Fahrenheit), Heart Rate 105, Respiratory Rate 16, Blood Pressure 125/84, and Oxygen Saturation 95%. The paramedic wrote at this time, "Patient observation: Observations: pt (patient) reassessed at this time, no changes noted."

On 6/17/21 at 2:15 AM, a paramedic recorded Vital Signs: Temperature 98.6 (degrees Fahrenheit), Heart rate 80, Respiratory Rate 16, Blood Pressure 128/86, Oxygen Saturation 95%. The paramedic wrote at this time, "Pt reassessed at this time, no changes noted."

On 6/17/21 at 2:26 AM, a basic metabolic panel (BMP) results were within normal range except for Glucose 127 HIGH (range 65-100).

On 6/17/21 at 2:58 AM, a complete blood count (CBC)) and differential specimen results were:
White Blood Count 25.5 HIGH (range 4.4-10.5), Hemoglobin HIGH 5.83 (range 4.0-5.65), Hematocrit 17.4 HIGH (range 36.9-48.5).

On 6/17/21 at 6:11 AM, a paramedic recorded Vital Signs: Heart Rate 105, Respiratory Rate 16, Blood Pressure 121/84, and Oxygen Saturation 97%. The paramedic wrote at this time, "Pt states no new or worsening changes."

On 6/17/21 at 7:20 AM, a nurse's note read, "Patient dismissed."

PHYSICIAN ORDERS

On 6/16/21 at 8:31 PM, the physician gave a verbal order for an "XR abdomen 1 view."

On 6/17/21 at 2:07 AM, the physician gave a verbal order for "CBC and Differential; basic metabolic panel."

DIAGNOSTIC TESTS

On 6/16/21 at 10:12 PM, the final report of the abdominal X-ray read, "Impression: Large stool primarily seen within the transverse colon through rectum. No definite obstructive pattern."

EMERGENCY DEPARTMENT LOG

The ED log indicated a disposition of "LWBS (left without being seen) after triage."

INTERVIEWS

On 7/22/21 at approximately 7:05 PM, the Operations Manager stated that nurses can order initial tests based on a patient's presentation, per an established protocol, with the physician giving the final authorization on such orders.

On 7/21/21 at 7:43 PM, Registered Nurse (RN) A stated the X-ray was ordered per physician verbal order. She stated the mother initially focused on abdominal pain. She stated the patient was placed in a consultation room and X-ray waiting room to help limit environmental stimulation since the patient was autistic.

On 7/22/21 at 1:20 PM, the Emergency Department physician who ordered the x-ray stated the nurse had communicated to him the patient's condition prior to the X-ray order having been placed. He stated the nurse did not ask him to evaluate the patient.

VIDEO

A video timeline of the patient's presentation, prepared by the hospital, reflected numerous instances of the patient running to the bathroom. On 6/17/21 at 4:02 AM, it also reflected that the patient's mother went to speak to the Triage nurse.

SUMMARY

All of the preceding interactions and physician orders attested to the patient having presented with an emergency medical condition and necessitating a medical examination.

There was no evidence of any physician involvement with the patient from the time in which the last blood results were available, on 6/17/21 from 2:57 AM to 7:20 AM, which is approximately four and one half hours. There was no evidence in the patient's medical record that a qualified emergency person performed a medical screening examination prior to the patient leaving the emergency department (ED).

SUMMARY INTERVIEW

On 7/22/21 at approximately 3:00 PM, the Risk Manager confirmed the entries in the medical record as quoted in prior text.

Based on hospital policy, emergency department log, video review, interview and record review, the hospital failed to provide further medical examination and treatment to stabilize the medical condition, and the hospital determined that 1 of 20 sampled individuals had an emergency medical condition (#1).

Findings:

NURSE'S NOTES

On 6/16/21 at 8:10 PM, an Emergency Department (ED) Triage nurse's note read, "Pt (patient) c/o (complains of) abd (abdominal) pain with n/v (nausea and vomiting) X (times) 3 today. Per mom patient is autistic and is afraid to have a BM (bowel movement), sts (states) that they are seeing PCP (Primary Care Provider) about this and have abd US (ultrasound) scheduled. Pt awake, alert and oriented. Respirations equal and unlabored."

On 6/16/21 at 8:16 PM, the patient was triaged at a level of "3". Per hospital policy "Patient Acuity and Nursing Assessment in the Emergency Department", a level III means: "Does not require immediate or prompt medical attention but care involves multiple hospital resources."

On 6/16/21 at 8:37 PM, the Heart Rate only was taken, and was 80.

On 6/16/21 at 8:43 PM, a Glasgow Coma Scale score was documented by a Registered Nurse (RN). The results were: Best eye response: spontaneous. Best verbal response: oriented. Best Motor response: follows commands. Glasgow Coma Scale score: 15.

On 6/16/21 at 8:44 PM, triage notes reflected Vital Signs as: Heart Rate 180; Respiratory Rate 17; Blood Pressure 140/114; Oxygen Saturation 95%.

On 6/17/21 at 12:07 AM, a paramedic recorded Vital Signs: Temperature 98.6 (degrees Fahrenheit), Heart Rate 105, Respiratory Rate 16, Blood Pressure 125/84, and Oxygen Saturation 95%. The paramedic wrote at this time, "Patient observation: Observations: pt (patient) reassessed at this time, no changes noted."

On 6/17/21 at 2:15 AM, a paramedic recorded Vital Signs: Temperature 98.6 (degrees Fahrenheit), Heart rate 80, Respiratory Rate 16, Blood Pressure 128/86, Oxygen Saturation 95%. The paramedic wrote at this time, "Pt reassessed at this time, no changes noted."

On 6/17/21 at 6:11 AM, a paramedic recorded Vital Signs: Heart Rate 105, Respiratory Rate 16, Blood Pressure 121/84, and Oxygen Saturation 97%. The paramedic wrote at this time, "Pt states no new or worsening changes."

On 6/17/21 at 7:20 AM, a nurse's note read, "Patient dismissed."

PHYSICIAN ORDERS

On 6/16/21 at 8:31 PM, the physician gave a verbal order for an "XR abdomen 1 view."

On 6/17/21 at 2:07 AM, the physician gave a verbal order for "CBC (complete blood count) and Differential; basic metabolic panel."

DIAGNOSTIC TESTS

On 6/16/21 at 10:12 PM, the final report of the abdominal X-ray read, "Impression: Large stool primarily seen within the transverse colon through rectum. No definite obstructive pattern."

On 6/17/21 at 2:26 AM, a basic metabolic panel (BMP) results were within normal range except for Glucose 127 HIGH (range 65-100).

On 6/17/21 at 2:58 AM, a complete blood count (CBC)) and differential specimen results were: White Blood Count 25.5 HIGH (range 4.4-10.5), Hemoglobin HIGH 5.83 (range 4.0-5.65), Hematocrit 17.4 HIGH (range 36.9-48.5).

EMERGENCY DEPARTMENT LOG

The ED log indicated a disposition of "LWBS (left without being seen) after triage."

INTERVIEWS

On 7/22/21 at approximately 7:05 PM, the Operations Manager stated that nurses can order initial tests based on a patient's presentation, per an established protocol, with the physician giving the final authorization on such orders.

On 7/21/21 at 7:43 PM, RN A stated the X-ray was ordered per physician verbal order. She stated the mother initially focused on abdominal pain. She stated the patient was placed in a consultation room and X-ray waiting room to help limit environmental stimulation since the patient was autistic.

On 7/22/21 at 1:20 PM, the ED physician who ordered the X-ray stated the nurse had communicated to him the patient's condition prior to the X-ray order having been placed but the nurse did not ask him to evaluate the patient.

VIDEO

A video timeline of the patient's presentation, prepared by the hospital, reflected numerous instances of the patient running to the bathroom. On 6/17/21 at 4:02 AM, it also reported that the patient's mother went to speak to the Triage nurse.

SUMMARY

All of the preceding interactions and physician orders attested to the patient having presented with an emergency medical condition and necessitating a medical examination.

There was no evidence of any physician involvement with the patient from the time in which the last blood results were available, on 6/17/21 from 2:57 AM to 7:20 AM, which is approximately four and one half hours. There was no documentation that the physician was notified of the abnormally high White Blood Count (WBC), which was reported on 6/17/21 at 2:58 AM. The patient left the ED without being seen by a physician, and without the elevated WBC being addressed.

SUMMARY INTERVIEW

On 7/22/21 at approximately 3:00 PM, the Risk Manager confirmed the entries in the medical record as quoted in prior text.