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Based on record review and interview, the physician failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department for Patient #3 to determine whether or not an emergency medical condition existed.


Refer to A2406.

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Based on record review and interview, the physician failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department for Patient #3 to determine whether or not an emergency medical condition existed.


Findings:

Patient #3 was a 3-year-old, male with autism, non-verbal who presented to the emergency department on 03/24/24 at 4:40 PM with complaints of "fevers and vomiting for 1 day. Symptoms started with upper respiratory symptoms, cough, congestion for 2 days. Parents report that he has vomited 5-6 times and is not tolerating water even. Parents deny any obvious illness exposure." The ED log documented an ESI Level 3 (the ESI (Emergency Severity Index) is a triage tool used in emergency departments to categorize patients based on the severity of their conditions and the resources they are expected to need. ESI levels range from 1, most urgent, to 5, least urgent). The patient was discharged home on 3/24/2024 at 6:49 PM with a diagnosis of "Viral intestinal infection, unspecified".


A review of the medical record revealed a Medical Screening Exam was conducted on 3/24/24 by Staff #9 PA (Physician Assistant) at 5:35 PM.

The medical screening exam revealed the following:
"Constitutional: Well-developed, well-nourished child who is awake, alert, cooperative with no acute distress.
Constitutional: The patient appears in no acute distress, alert
Eyes: Pupils: equal, round, and reactive to light, Conjunctiva: normal
ENT: TM's are normal, Nose: nasal drainage, that is minimal and is seen coming from both nares, that is clear. Mouth: is normal, Posterior pharynx: is normal.
Respiratory: the patient does not display signs of respiratory distress, Respirations: normal, Breath sounds: are normal, clear throughout.
Cardiovascular: Rate: normal, Rhythm: regular, Heart sounds: normal
Abdomen/GI: Bowel sounds normal, Palpation: abdomen is soft and non-tender, in all quadrants.
Skin: rash, is not appreciated.

A review of the Physician Assistant orders and results revealed the following:

Flu A/B Sofia (Within Normal Limits)
COVID-19 AG (Within Normal Limits)
Strep A Assay W-Opti (Within Normal Limits)
Zofran IM 2mg"

A review the medical record of the Emergency Room Nurse's documentation revealed the following vital signs for Patient #3.

"3/24/2024 5:04 PM:
Blood pressure was not obtained.
Pulse: 170
Respirations: 32
Temperature 99
Oxygen Saturation 100% Room Air

3/24/2024 6:49 PM
Blood pressure was not obtained.
Pulse: 138
Respirations: 29
Temperature was not obtained.
Oxygen saturation: 100% on Room Air"

Patient #3 was discharged by Staff #9, PA, on 03/24/24 at 6:45 PM.

The Discharge Assessment documented the following:
"Patient awake and alert. Discharge instructions given to patient, instructed on discharge instructions, follow-up, and referral plans. Medication usage demonstrated understanding of instructions medications; Prescriptions are given x1."

A review of the "Discharge Disposition/Summary" revealed the following:

Discharge: Home
Condition: Improved
Diagnosis: Viral intestinal infection, unspecified
Follow-up: Private physician, 2-3 days
Prescriptions: Ondansetron 4mg Oral tablet, disintegrating"


A review of the facility policy titled; "Pediatric Trauma Assessment and Resuscitation" dated 01/2023 revealed:

"...4. Obtain a complete set of vital signs including respiration rate, pulse oximetry, and blood pressure. Use cardiac monitoring whe patients' injuries necessitate monitoring. Continuing to reassess all vitals as needed.

5. Reference nationally recognized guidelines including ATLS, TNXX, ENPC, PALS, Broselow Tape, and Harriet Lane Handbook for all pediatric/infant age group standards of care...."

Based on the guidelines from various pediatric care courses and references, including PALS (Pediatric Advanced Life Support), the Harriet Lane Handbook, a normal heart rate range for a 3-year-old child typically is between 70 and 110 beats per minute (bpm) at rest.


Further review of the medical record revealed there was no complete blood count (CBC) to assess for leukocytosis indicative of sepsis, a comprehensive metabolic panel (CMP) to evaluate renal function and electrolyte balance disrupted by hypovolemia from vomiting, or a urinalysis to detect ketones suggesting severe dehydration or urinary tract infection (UTI). Also, screening tests for sepsis C-reactive protein (CRP), procalcitonin, and blood cultures were not ordered. There was no electrocardiogram (ECG) performed to rule out significant arrhythmias like supraventricular tachycardia (SVT) as the cause of tachycardia.

PA #9 did not assess oral intake and hydration status PO challenge. A PO challenge is a medical test where a person swallows (orally takes) a specific substance, usually a food or medication, under controlled conditions to ensure safety and to observe how the person's body responds to the substance, helping doctors diagnose and manage potential blockages or related issues in the digestive tract. Failure to perform this PO challenge could have warranted further investigation. There were no imaging studies performed. An abdominal series or CT scan could have assisted in ruling out intraabdominal conditions such as bowel obstruction, appendicitis, or ileus.


Patient #3 presented to Hospital #2 on 03/25/2024 at 3:55 PM.

A review of the medical record revealed a CT with contrast of abdomen and pelvis was ordered. A computed tomography (CT) scan is a medical imaging procedure that uses X-ray images taken from various angles around the body. The CT scan results in the medical record noted "fluid-filled loop of small bowel in the lower abdomen which is distended with fecilization. Question chronic partial small bowel obstruction versus chronic ileus... a large amount of stool throughout the colon with stool-like material in the distal ileum-constipation vs partial small bowel obstruction 2/2 bezoar vs meckel's diverticulum."

Patient #3 was then transferred to pediatric Hospital #3 on 03/26/2024 with post operative report dated 03/27/24 revealing the patient had an "intestinal obstruction" with procedures performed.

"Laparoscopy" Abdomen/peritoneum/omentum/diagnostic and Enterotomy Exploration or foreign body removal."

A review of Hospital #3's "Discharge Summary" revealed "During admission, the patient was on IV pain medications with an NGT (nasal gastric tube) to LIWS (low intermittent wall suction). The patient underwent Gastroview protocol with contrast reaching the rectum within 21 hours. However, due to persistent bilious NGT output and no BM ' s the decision was made to proceed to the OR. The patient was taken to the OR with the surgeon on 3/27/2024 for exploratory laparoscopy with enterotomy for bezoar removal. The patient tolerated the procedure well and was admitted post-operatively for NGT management, pain control, monitoring for complete return of bowel function, and advancement of diet."

An interview with Staff #12, Emergency Room Physician on 5/7/2024 at 11:01 AM in the Emergency Department stated, "The one thing that I would have done is an oral challenge to make sure that the child could tolerate water before discharging. If they cannot tolerate anything by mouth, it would prompt me to do other diagnostic testing. I wouldn't have discharged the patient without the oral challenge though."

An interview with Staff #13, Emergency Room Physician and supervisor of Staff #9, PA, on 5/07/2024 at 11:20 via telephone call stated: "After hearing the scenario, I would have done an oral challenge to ensure the patient could tolerate fluids before discharging home. As far as diagnostic testing such as blood work and x-rays, it would have been determined based on the oral challenge."