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Based on interview and record review, the facility failed to ensure full medical examination and treatment was provided timely, for one of 22 sampled patients (Patients 22).

This failure had the potential to affect the patients' health and safety and may result in a delay in treatment.

Findings:

On August 6, 2024, at 1:45 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated he heard a five year old female child (Patient 22) came in with a respiratory infection and was discharged possibly four to five months ago. He stated the day following the Patient 22's discharge, the patient was brought back into the Emergency Department (ED) in full arrest (condition when a patient stopped breathing and the heart stopped beating). He stated cardiopulmonary resuscitation (CPR, chest compressions to attempt to revive a person) was performed but Patient 22 expired.

On August 6, 2024, at 2 p.m., an interview was conducted with Physician 1. Physician 1 stated he clearly remembered Patient 22 as he was the physician who ran the code (code blue, a hospital code for a patient who is needing to be revived) when Patient 22 came in. He stated Nurse Practitioner (NP) 1 saw Patient 22 in the Rapid Medical Exam (RME, area of the ED for patients who need to be examined) area on the first time the patient was brought to the ED. He stated he could not recall Patient 22's name, but the incident occurred between January to March of 2024.

On August 6, 2024, at 3 p.m., a concurrent interview and review of Patient 22's record were conducted with the Quality Manager (QM). A facility document titled, "...Emergency Department Record- Pediatric- Scribe to Mid-Level," dated February 24, 2024, authored by NP 1, indicated, "...Patient [Patient 22] is a 5 [five] year old...broguht in...for evaluation of fever, congestion, runny nose, cough x 2-3 [two to three] days ago. Patient reporting chest pain and dysuria [difficulty in urination]...ED Course/Medical Decision Making...Orders placed for urine [laboratory test] and...Chest [chest xray, an imaging procedure] 2 [two] View...Patient administered Tylenol [a pain and fever reducing medication] 325/mg [milligram, unit of measurement] 10.15 mL [milliliter, unit of measurement] PO [by mouth] and Ibuprofen [a pain and fever reducing medication] 340 mg/17 mL PO. Will continue to monitor...2311 [11:11 p.m.]: Nurse reports repeat temp [temperature, normal temperature in children is 97.6 to 99.3 F] is 102.7 [degrees Fahrenheit, F, a unit of measurement] after patient received meds [medications] 40 minutes ago...2337 [11:37 p.m.]: Nurse reported that repeat temp is 103 [F]. Patient given ice packs...0020 [12:20 a.m.]...Repeat temperature is 101.8 [F]..."

A facility document titled, "ED Summary Report," dated February 24, 2024, indicated, "...Vital Signs...02/24/2024 [February 24, 2024] 21:36 [9:36 p.m.]...Temp 101.1 F...BP [blood pressure] [no entry indicated]...Pulse [heart rate] 160 [beats per minute, bpm; normal heart rate in children is 80-140 bpm]...Resp [respirations] 20...O2 sat [oxygen saturation, level of oxygen in the blood] 98%...23:13 [11:13 p.m.] Temp 102.7 F...[no entries were documented for the BP, pulse, respiration, O2 sat]...02/25/2024...00:17 [12:17 a.m.]...Temp 102.1 F...no entries were documented for the BP, pulse, respiration, O2 sat]..."

A facility document titled, "Medication Administration Record," dated February 24, 2024, indicated, "...Scheduled Meds...Acetaminophen [a fever reducing medication]-STAT [to administer immediately]...325 MG/10.15ML...Admin [administered] 02/24 [February 24, 2024] 22:49 [10:49 p.m.]...Ibuprofen-STAT...100 MG/5ML...Admin...02/24...22:39 [10:39 p.m.]..."

A facility document titled, "Diagnostic Imaging Department," dated February 24, 2024, at 11:49 p.m., indicated, "...Impression...Right middle lobe pneumonia [a lung infection]..."

A facility document titled, "Discharge Assessment/Summary Report," indicated, "...Patient [Patient 22] departed from the ED Date and Time 02/25/2024 [February 25, 2024] 12:24 a.m..."

A facility document titled, "...Emergency Department Record Pediatric- Scribe to Physician," indicated, "15:55 [3:55 p.m.]: Patient brought in by [family member]...No pulses were felt. CPR began immediately. Code Blue initiated...Time of death pronounced at 1645 [4:45 p.m.]..."

There was no documented evidence a complete set of vital signs which included pulse, BP, respirations, O2 sat, and pain were taken for Patient 22 during her first visit to the ED on February 24, 2024, until she was discharged on February 25, 2024, at 12:24 a.m. There was no documented evidence Patient 22's vitals were taken prior to being discharged.

There was no documented evidence laboratory tests aside from chest x-ray and urinalysis were done for Patient 22.

The QM stated Patient 22's acuity Emergency Severity Index (ESI, a tool used in the ED to determine which patient needs urgent attention with level 1 meaning immediate medical care is needed, patients classified as level 2 and 3 means care is needed within 15 minutes, and those classified as level 4 and 5 means care is needed within 30 minutes) level was a three.

On August 6, 2024, at 4:26 p.m. a concurrent interview and review of Patient 22's record were conducted with Physician 1. Physician 1 stated vital signs should be taken when patient comes in and prior to discharging the patient to ensure the patient is stable. Physician 1 stated the cause of cardiac arrest (when the heart stopped beating) for Patient 22 could have been possible pneumonia leading to sepsis (a life threatening infection in the blood). He further stated vital signs and laboratory tests would indicate if a patient has sepsis.

On August 6, 2024, at 4:56 p.m., an interview was conducted with NP 1. NP 1 stated vitals should have been taken at discharge. She further stated she requested vitals prior to discharginf Patient 22 but she was not sure what they were if they were not documented.

A review of the policy and procedure (P&P) titled, "Discharge From Emergency Department," dated August 2019, was conducted. The P&P indicated, "...After being evaluated in the Emergency Department (ED) by a Licensed Independent Practitioner (LIP) and/or MD, appropriate discharge planning for a patient includes completing a medical record, making a plan for follow-up care suitable to the individual patient's needs...Documentation appropriate for the patient will occur within the Discharge Tab in EMR...A discharge assessment shall be completed prior to leaving the ED..."

A review of the P&P titled, "Triage And Assessments Of Patients Using The Emergency Severity Index (ESI)," dated, April, 2023, was conducted. The P&P indicated, "...To ensure that every patient receives efficient and appropriate medical care based on his/her Emergency Severirty Index (ESI)...Complete a triage to determine the patient's condition...This initial triage should include...An assessment of the patient's vital signs...ESI LEvel 3: Urgent; Stable iwth multiple types of resources needed to investigate or treat (such sa lab tests and x-ray imaging)...The patient presents with a condition that could progress to a serious problem requireing emergency interventions...The vital signs of a Level 3 patient may or may not be outside of normal limits (danger zone)..."