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Based on medical record review, policy/procedure review, and staff interview, the hospital administrative staff failed to enforce policies/procedures requiring a Medical Screening Exam (MSE) for 1 of 40 patients, (Patient #1) presenting with an emergency medical condition to the Emergency Department (ED) on 4/7/13. The hospital administrative staff identified an average daily census of 7 pediatric Emergency Department patients.

Findings include:

1. Review of the hospital policy/procedure titled "EMTALA: The Treatment and Transfer of Individuals Who Request Emergency Medical Service," effective 6/2011, revealed in part, the following: "The hospital will provide an appropriate medical screening examination within the capability of the Hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition exists. . . ."

2. Review of Patient #1's ER medical record dated 4/7/13 at 5:32 PM revealed:

Patient brought to the ER by his/her mother. The initial triage nursing assessment at 5:40 PM documented the patient had vomiting last night and blood in his stool (brought diaper). Patient had vomiting 2 times today, at first green and now brown, a decrease in wet diapers and a fever. Patient had decreased intake, abdominal tenderness and was crying at home. Patient also presented on 4/7/13 at 4:00 AM with the same symptoms and was discharged.

The History of Present Illness documented by Practitioner A, MD (Medical Doctor) revealed a concern for intussusception (telescoping of the bowel that could result in an obstruction). Mother stated, patient here last night with intermittent, generalized abdominal pain, a rapid heart rate of 140 beats a minute and no sleep for the last 10 hours. Patient has had persistent crying with episodes that are worse at times. Patient not making tears when crying (possible sign of dehydration).

The initial physician exam revealed the patient had tachycardia (rapid heart rate), dry mucous membranes, abdominal tenderness and severe abdominal guarding, inconsolable and in moderate distress.

Review of the ED course documented by Practitioner A revealed:

Patient given Zofran (anti-nausea medication). Tolerating fluids by mouth with no episodic pain. Normal bowel gas pattern.

Review of the ED Physician Orders showed the physician ordered:

IV fluids 200ml bolus. Stat (immediate) X-ray. At 7:20 PM Zofran 2mg ODT.

Review of the final report and the abdominal x-ray 2 views showed no extra luminal gas (no free air or perforation). Gas pattern is within normal limits, non obstructive in nature.

The clinical impression/diagnosis documented by Practitioner A showed a final diagnosis of, nausea, vomiting, and blood streaked stool.

Discharge instructions provided and signed by parent and practitioner including: have the patient rest more than usual, provide soft, bland foods until feeling better, give extra fluids to drink and follow up with primary physician if not better in 2 days.

3. During an interview on 4/16/13 at 1:00 PM, Practitioner A, MD stated the patient presented to the ER with vomiting and bloody stool. The assessment documented blood streaked stool, the blood observed was outside the stool and could indicate bleeding in the lower gastrointestinal (GI) tract. Patient had episodic abdominal pain (comes and goes), but no masses palpated. Patient did not have tears with crying.

Practitioner A said an occult stool sample (test for blood in stool) showed positive for blood in the stool, but patient had no fissure (a long narrow opening; a crack or cleft) noted. An abdominal x-ray showed no extraluminal gas and no obstructions in the bowel.

Practitioner A said he did not consult a pediatrician because ER physicians are trained to evaluate pediatric patients as well as adults. I did consider intussusception and this is why I did the abdominal x-ray. Although I documented the child's abdomen was tender with severe guarding, essentially that meant the belly muscles were flexed but the child was crying during the exam which could cause the belly muscles to be flexed, this would be non-specific.

The physician failed to follow the hospital policy and conduct a complete medical screening exam for this patient by not acquiring blood tests or a gastrointestinal test to identify any other possible causes for the pain and blood in the stool. Documentation showed the practitioner suspected intussusception, but failed to provide stabilizing treatment for this emergency condition. Staff also failed to evaluate the patient for dehydration prior to discharge (see A2406)

Based on review of policy/procedure, documentation, and staff interviews, the hospital failed to provide a complete medical screening examination for 1 of 40 patients, (Patient #1) to determine if Patient # 1 had an emergency medical condition during their second presentation to the hospital seeking emergency care on 4/7/13. The hospital administrative staff identified an average daily census of 7 pediatric Emergency Department patients.

Findings include:

1. Review of the hospital policy/procedure titled "EMTALA: The Treatment and Transfer of Individuals Who Request Emergency Medical Service," effective 6/2011, revealed in part, the following: "The hospital will provide an appropriate medical screening examination within the capability of the Hospital's dedicated emergency department, including ancillary services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition exists. . . ."

2. Review of Patient #1's ER medical record dated 4/7/13 at 5:32 PM revealed:

Patient brought to the ER by his/her mother. The initial triage nursing assessment at 5:40 PM documented the patient had vomiting last night and blood in his stool (brought diaper). Patient had vomiting 2 times today, at first green and now brown, a decrease in wet diapers and a fever. Patient had decreased intake, abdominal tenderness and was crying at home. Patient also presented on 4/7/13 at 4:00 AM with the same symptoms and was discharged.

Review of the Interdisciplinary notes revealed, Staff A, RN (Registered Nurse) documented:
a. At 5:50 PM, evaluated the stool and noted large brown bowel movement with scant blood.
b. At 6:50 PM, attempted to start intravenous line (IV) 2 times without success.
c. At 7:20 PM, staff administered Zofran 2mg ODT (oral dissolvable tablet) x1. Will push fluids by mom.
d. At 8:15 PM, Patient's parents presented with discharge instructions and a prescription for Zofran (anti-nausea medication). All questions answered with no concerns.

The History of Present Illness documented by Practitioner A, MD (Medical Doctor) revealed a concern for intussusception (telescoping of the bowel that could result in an obstruction). Mother stated, patient here last night with intermittent, generalized abdominal pain, a rapid heart rate of 140 beats a minute and no sleep for the last 10 hours. Patient has had persistent crying with episodes that are worse at times. Patient not making tears when crying (possible sign of dehydration).

The initial physician exam revealed the patient had tachycardia (rapid heart rate), dry mucous membranes, abdominal tenderness and severe abdominal guarding, inconsolable and in moderate distress.

Review of the ED course documented by Practitioner A revealed:

Patient given Zofran (anti-nausea medication). Tolerating fluids by mouth with no episodic pain. Normal bowel gas pattern.

Review of the ED Physician Orders showed the physician ordered:

IV fluids 200ml bolus. Stat (immediate) X-ray. At 7:20 PM Zofran 2mg ODT.

Review of the final report and the abdominal x-ray 2 views showed no extra luminal gas (no free air or perforation). Gas pattern is within normal limits, non obstructive in nature.

The clinical impression/diagnosis documented by Practitioner A showed a final diagnosis of, nausea, vomiting, and blood streaked stool.

Discharge instructions provided and signed by parent and practitioner including: have the patient rest more than usual, provide soft, bland foods until feeling better, give extra fluids to drink and follow up with primary physician if not better in 2 days.

3. During an interview on 4/16/13 at 3:55 PM, Staff A stated the physician ordered an IV bolus 200cc fluids for patient. Two staff attempted to insert the IV without success. Physician notified no IV access obtained and ordered Zofran 2mg (milligrams) ODT (oral dissolvable tablet and push fluids at 7:20 PM. The patient received the medication and patient's mother able to get 100cc fluid in patient. The patient did not have further vomiting after the medication administered.

4. During an interview on 4/16/13 at 1:00 PM, Practitioner A, MD stated the patient presented to the ER with vomiting and bloody stool. The assessment documented blood streaked stool, the blood observed was outside the stool and could indicate bleeding in the lower gastrointestinal (GI) tract. Patient had episodic abdominal pain (comes and goes), but no masses palpated. Patient did not have tears with crying.

Practitioner A said an occult stool sample (test for blood in stool) showed positive for blood in the stool, but patient had no fissure (a long narrow opening; a crack or cleft) noted. An abdominal x-ray showed no extraluminal gas and no obstructions in the bowel.

Practitioner A said he did not consult a pediatrician because ER physicians are trained to evaluate pediatric patients as well as adults. I did consider intussusception and this is why I did the abdominal x-ray. Although I documented the child's abdomen was tender with severe guarding, essentially that meant the belly muscles were flexed but the child was crying during the exam so which could cause the belly muscles to be flexed, this would be non-specific.

The State Quality Improvement Organization provided a physician peer review, dated 4/29/13, that revealed the hospital did not provide a complete medical screening examination of this pediatric patient with bloody diarrhea. The review determined the patient needed evaluation of stability of blood counts [blood tests] and a work up for the concern of Intussusception. The review determined presence of an emergency medical condition due to bloody diarrhea in an infant, dehydration with inability to start an intravenous line for fluids and lack of success in adequate oral hydration.