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Based on policy review, patient and staff interviews, the hospital inappropriately discharged 1 (Patient 4) of 20 sampled patients, prior to providing within the hospital's capabilities, a Medical Screening Examination (MSE) sufficient to determine whether Patient 4 was dehydrated and if the presence of an Emergency Medical Condition (EMC) existed, in accordance with the facility Emergency Medical Treatment and Transfer Policy (EMTALA).
Patient 4 presented to the Emergency Department seeking medical care for dehydration and the staff failed to provide an adequate MSE to assess the state of dehydration. The failure to follow the hospital's policy and procedures for performing a MSE to determine an EMC has the potential to cause harm or death due to a delay in treatment.

Findings are:

See also A 2406.

A. Review of facility policy titled "Emergency Medical Treatment and Active Labor Act" last revised 9/2019 states, "A medical screening examination is provided at (facility) to any person presenting themselves anywhere on the (facility) campus who is seeking emergency services to determine whether that person has an emergency medical condition." The medical screening data is collected by qualified personnel, the final determination of whether an emergency medical condition exists can only be made by a physician. The medical screening includes: a) a brief, general history; b) appropriate physical examination including the presenting complaint; c) supportive diagnostic evaluation; d) consultation to the extent felt necessary by physician; e) the level of complexity/acuity may require the use of ancillary services; f) each medical staff member must assure timely availability (physically available within 30 minutes)

B. The hospital failed to follow the policy titled "Emergency Medical Treatment and Active Labor Act" and did not provide a medical screening exam sufficient for Patient 4 when the patient presented to the dedicated emergency department with complaint of vomiting and dehydration on 10/8/21 at 6:33 AM and dismissed at 8:15 AM. Patient 4 was evaluated 4.5 hours later at the primary care doctors office and admitted directly to the hospital for intractable vomiting; high anion gap metabolic acidosis; dehydration and gastroenteritis provided IV therapy. Patient 4 was discharged on 10/10/21 at 3:25 PM.

C. An interview with RN B on 1/26/22 at 11:15 AM revealed, "I know the Mom was upset that we did not provide (Patient 4) with IV's." When asked if RN B was aware if the infant drank anything while in the ED and if so how much, RN B indicated that the infant was given oral Tylenol and kept that down, "I do not know about anything else, but did document no vomiting while here." Inquired if there was documentation on the amount of intake in the record related to the nurses note, "Pt drank small amount with no vomiting during visit." RN B replied "No."

Based on policy review, patient and staff interviews, the hospital inappropriately discharged 1 (Patient 4) of 20 sampled patients, prior to providing within the hospital's capabilities, a Medical Screening Examination (MSE) sufficient to determine whether Patient 4 was dehydrated and if the presence of an Emergency Medical Condition (EMC) existed. The total sample of 20 patients were reviewed. This failure has the potential for all patients presenting to the Emergency Department (ED) to have an untreated MSE which could result in harm or death due to delay in treatment. According to the facility provided information the ED sees an average of 1366 patients per month.

Findings are:

A. In an interview with Patient 4's mother, on 1/24/22 at 2:45 PM, revealed that she took their 10 month old into the emergency department on 10/8/21 at 6:33 AM, after the infant had been ill for 2 days and having vomiting, he did not have a wet diaper for over 12 hours and refusing liquids and was lethargic. She said they were in a room and the ED Doctor came into the room and checked him over. She had told the doctor that she felt the infant was dehydrated and needed IV fluids. She said that the ED Doctor said that he had some shallow sores in the back of his mouth but did not appear "clinically dehydrated." The ED Doctor had the nurse give him some Tylenol and asked me to give some fluids. Our son refused to drink for me, but the nurse and doctor disregarded the information and "my pleas to give him some IV fluids" and discharged him. We were provided information about dehydration signs and symptoms in infants, "which I think he already showed" and told to give him Tylenol every 4 hours and return if needed. We called our family doctor before we even left the hospital and got an appointment for 1:00 PM that day. When our doctor saw our son at his office, he directly admitted him to the hospital for severe dehydration. We were in the hospital for 3 days, he was diagnosed with gastroenteritis (stomach virus) and sent home on 1/4 strength formula that we increased over 2 weeks before his diet normalized.

B. Review of Patient 4's 10/8/21 ED medical record showed the infant arrived at 6:33 AM, the patients vital signs (VS) were 98.7 rectal, heart rate 133, respirations 44, oximetry (measurement of oxygen) 100% and weight 21 pounds 0.5 ounces. The ED Doctor examined Patient 4 at 6:56 AM. The ED medical record identified that the infant had been vomiting for 2 days and was able to tolerate about a 1/2 ounce yesterday, no fever, no cough or congestion, last wet diaper was 2:00 PM on 10/7/21. It was noted that the infant had 2 hard stools yesterday and vomiting, decreased urine volume, exam showed a few small scattered ulcerations (sores) on the soft palate (area in the back of mouth). Diagnosis management comments: "Patient given oral Tylenol (pain medicine) and then fell asleep and did not want to feed." "Suspect this is all viral illness, advised Tylenol through the day for the soft palate ulcers and push small amount of fluid." Diagnosis included Vomiting, intractability (unable to control) of vomiting. Home instructions included follow up with Family Medicine Doctor as soon as possible for a visit in 1 day; written information "Diet for vomiting/diarrhea infant/toddler"; and to return to the emergency department for worsening symptoms. Discharged home at 8:15 AM.

C. Review of Patient 4's 10/8/21 ED medical record nurses documentation by Registered Nurse B (RN B) identified every 15 minute pulse rate monitoring with a range from 119-134 per minute and pulse oximetry 99-100%. RN B documented at 8:15 AM upon discharge that the patient's Mother was upset that the patient did not get IV fluids. Pt drank small amount with no vomiting during visit. Mother states "she will go to his Primary Care Physician and that she doesn't trust this ER."

E. An interview with RN B on 1/26/22 at 11:15 AM revealed, "I know the Mom was upset that we did not provide (Patient 4) with IV's." When asked if RN B was aware if the infant drank anything while in the ED and if so how much, RN B indicated that the infant was given oral Tylenol and kept that down, "I do not know about anything else, but did document no vomiting while here." Inquired if there was documentation on the amount of intake in the record related to the nurses note, "Pt drank small amount with no vomiting during visit." RN B replied "No."

F. Review of Patient 4's Inpatient medical record for 10/8/21 at 1:49 PM and dismissed on 10/10/21 at 3:25 PM identified:
-The patient's admission diagnoses as Dehydration (when more fluids leave the body than enter it); Noninfective gastroenteritis and colitis (an inflammation of the gut that can cause vomiting / diarrhea) and acidosis (an issue that indicates an imbalance in the electrolytes which can be due to dehydration.).
-The 10/8/21 History and Physical for Patient 4 revealed, Review of Systems and Physical Exam: positive for vomiting; skin pallor (pale); overall listless, but responsive and makes good eye contact; VS 106/65, pulse 150, rectal temp 98.6, respirations 40, oximetry 96% and weight 20 pounds 5.2 ounces. Labs & Imaging: CXR (Chest X Ray) with central thickening, suggestive of viral process. Labs overall reassuring. Increased anion gap metabolic acidosis. Assessment: Gastroenteritis; Vomiting; Dehydration; Elevated anion gap metabolic acidosis. The 10/8/21 lab showed WBC (white blood count) 13.4 (slightly elevated 5.0-11.0) Anion Gap 30 (Slightly elevated 10-20)
-The Admitting Nurse noted that the IV was placed by a Vascular Access RN (a specialty nurse that places IV's) after 3 failed attempts. (Patient 4) was given a bolus of sodium chloride 0.9% of 190.8 ml (millilter) over 1 hour then decreased to a maintenance rate.
-The 10/10/21 Discharge Summary revealed the Discharge Diagnoses: Intractable vomiting; High anion gap metabolic acidosis; Dehydration; Gastroenteritis. The Hospital Course: He was admitted due to vomiting and dehydration and started on IV fluids. He continued to have episodes of vomiting. This resolved after the strength of his formula was decreased. He tolerated 1/2 strength formula and was discharged to home.