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Based on review of clinical records, review of the hospital's policies and procedures and internal documentation, and staff interviews, it was determined the hospital failed to enforce compliance with all requirements of 489.24 including providing necessary stabilizing treatment to an infant with a life threatening emergency.

Findings include:

Tag A-2407: Stabilizing Treatment

Patient #1 was a pediatric patient taken to the Emergency Department on 1/5/2010, with signs and symptoms consistent with an emergency condition. Intravenous antibiotics were not administered to the patient until almost 5 hours after the patient arrived. The patient's condition deteriorated, and he was transferred to a hospital with a Pediatric Intensive Care Unit almost 7 hours after he arrived. The patient was received at that hospital in severe distress and required immediate resuscitative measures.

Based on review of clinical records, review of the hospital's policies and procedures and internal documentation, and staff interviews, it was determined the hospital failed to provide necessary stabilizing treatment to an infant with a life threatening emergency (Patient #1).

Findings include:

The Hospital's policy titled, Emergency Medical Treatment and Active Labor Act (EMTALA) and Direct Admission Procedure, included the following:

"III. DEFINITIONS...Medical Screening Examination (MSE): is a non-discriminatory process required to determine within reasonable confidence whether an Emergency Medical Condition (EMC) does or does not exist and whether a woman having contractions is in need of immediate medical attention...Emergency Medical Condition (EMC): means a medical condition manifesting itself by acute symptoms of sufficient severity...Stabilized: means, with respect to an EMC, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility...IV. PROCESS...C. Emergency Medical Condition (EMC): Following the MSE it is determined if the patient has an EMC. An EMC is present when the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual...in serious jeopardy...When it has been determined that the individual has an EMC: the Hospital, within the capability of the staff and facilities available at the Hospital, shall stabilize the individual to the point where the individual is either 'stable for discharge' or 'stable for transfer' as defined; or provide for an appropriate transfer of the unstabilized individual to another medical facility in accordance with these procedures. Transfers of unstabilized individuals are allowed only upon an individual's request or when a physician or a QMP (Qualified Medical Person) in consultation with a physician certifies that the expected benefits to the individual from the transfer outweigh the risks of transfer...D. Stabilizing Treatment 1. To Stabilize means, to either provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during, the transfer of the individual from a facility, or that the EMC has been resolved...For patients whose EMC has not been resolved, the determination of whether they are stable, 'medically' may occur in one of the following two circumstances:...3. Stable for Transfer: the physician, or a QMP in consultation with the physician, determines within a reasonable medical probability that the individual sustains no material deterioration in his/her medical condition as a result of the transfer, and that the receiving facility has the capability to manage the EMC and any reasonably foreseeable complications. If an individual has an EMC, which has not been stabilized, the individual may be transferred only if the transfer is carried out in accordance with the procedures set forth below...Physician Certification is obtained, which is written certification by the treating physician ordering the transfer. Prior to the transfer the physician makes the determination that the benefits of transfer outweigh the risks of transfer."

Documentation in Patient #1's clinical record at Carondelet St. Joseph's Hospital revealed he arrived at the Emergency Department (ED) on 01/05/10 at 7:03 p.m. and was triaged by a Registered Nurse (RN) at 7:20 p.m. The RN documented the patient's chief complaint was "fever, vomiting," and the Triage Assessment was: "Mom states pt started feeling poorly last night, (+) N/V (nausea/vomiting) all day, sleepy, @ 1815 (6:15 p.m.) mom checked on him, he is covered (with) rash & bruising over entire body & bluish tinge to lips." The patient's vital signs were recorded at 7:25 p.m. as follows: Temperature 99.3 degrees Fahrenheit rectally; Pulse 172 beats per minutes; Respirations 36 breaths per minute; and oxygen saturation 100%. The patient's blood pressure was not recorded. The patient's heart rate and respiratory rate were abnormally high according to documentation in the preprinted guidelines attached to the nursing assessment as follows: "Vital Sign Norms: Pediatric" for a 1-year-old patient were: Heart rate (beats per minute) = 90-120; Respirations (breaths per minute) = 20-30; Systolic blood pressure (mm Hg) = 80-100.

Documentation in the ED Flowsheet revealed the infant patient was carried by his mother from the triage area to Room 21 in the ED, assessed by an RN and connected to an oxygen saturation monitor at which time the patient's oxygen saturation level was documented to be 96% on room air. The RN's initial assessment of the patient included: "...(-) troubles breathing; (+) fevers per (M) today...pt sleepy...per (M), pt was taking fluids, but would then vomit...Small bruises/purpura noted all over pts body, per (M) started x1-2 hours ago...Lips noted to be pale...."

The RN documented the ED physician was at the patient's bedside at 7:40 p.m. The Emergency Center Initial Orders were signed, dated, and timed by the physician on "1/5/09" (sic) at "1940" (7:40 p.m.). The physician's orders included labwork diagnostic studies including the following: catheterized urine specimen; CBC with auto diff (differential); Comprehensive Metabolic Panel, PT w/INR, Blood cultures x 1; chest x-ray; intravenous bolus of Normal Saline (NS) 400 ml then continue at 40 ml/hour; Zofran (anti-nausea medication) 2 mg ODT (oral disintegrating tablet). The physician also ordered a lumbar puncture consent be obtained from the patient's parent(s), a lumbar puncture tray for the procedure, and that the cerebrospinal fluid (CSF) obtained from the procedure be sent to the laboratory for cell count, protein, glucose and gram stain.

Documentation in the clinical record including nursing ED Flowsheets, physician's orders, and laboratory reports included the following sequence of events:

-8:10 p.m. (January 5, 2010): The RN inserted a pediatric catheter for a urine specimen, however there was no urine return. The physician was notified.
-8:20 p.m.: The patient's vital signs were: Pulse 172; Respiratory Rate 40, oxygen saturation 100% on room air. The patient's temperature and blood pressure were not recorded. A blood culture was also obtained from the patient's left hand at that time.
-8:30 p.m.: An intravenous (IV) was started in the patient's right antecubital and blood for CBC, CMP and PT w/INR were obtained to be sent to the laboratory.
-8:40 p.m.: NS 400 ml bolus IV hung and completed at 11:40 p.m.
-9 p.m.: Zofran 2 mg ODT administered.
-9:05 p.m.: Patient taken to radiology with parents.
-9:13 p.m.: Lab personnel contacted the RN to report the patient's blood glucose was "53" (the normal random glucose reference range is 74-106 mg/dL). The RN notified the physician who ordered Dextrose 10 gm by IV, and the order was scanned to pharmacy.
-9:35 p.m.: The patient was reassessed by the RN who documented "NC" (No change from prior assessment) except for the following: "pt alert & more aware now...(-) emesis now...more purpura/bruises noted now & larger in size."
-9:50 p.m. The lumbar puncture was performed after consent obtained from the parent(s).
-10:20 p.m.: The patient's vital signs recorded as a "late entry" were: "HR" (Heart Rate) 185; Respiratory rate 40; oxygen saturation level 100% on room air. The patient's temperature and blood pressure were not recorded.
-10:40 p.m.: Telephone call placed to Hospital #2. This was documented in the "Emergency Patient Transfer Out Physician Phone Log" which is not a part of the medical record.
-11 p.m.: Documentation in the EMTALA Consent/Transfer/Certification Form revealed the name of the accepting physician at Hospital #2 was contacted.
-11:20 p.m.: The physician wrote orders for Dexamethasone (steroid) 5 mg IV; Cefotaxime (antibiotic) 550 mg IV; and NS 200 ml bolus IV.
-11:30 p.m.: The patient's vital signs were recorded as follows: Temperature 100.3 (route not documented); Pulse 197; Respiratory Rate 45; Blood Pressure 68/38; oxygen saturation level 100% on room air. The patient's temperature was not documented in the clinical record after this time.
-11:35 p.m.: The RN inserted a pediatric catheter and obtained the urine sample. The RN reassessed the infant and documented "NC" in all areas except for the following: "making urine...purpura/bruising noted also on tongue now." The RN documented in the narrative notes: "MD notified of pts BP. Per MD, continue IV bolus. Will continue to monitor."
-11:40 p.m. NS 200 ml bolus IV hung and completed at 12:15 a.m..
-11:50 p.m.: Dexamethasone 5 mg administered IV.
-12:01 a.m. (January 6, 2010): Cefotaxmine 550 mg administered IV.
-12:10 a.m.: Dextrose 10, 100 ml was hung for infusion via IV.
-12:15 a.m.: The patient's vital signs were recorded as follows: Pulse 190; Respiratory rate 44; Blood Pressure 111/33; oxygen saturation 98.7% on room air. There were no vitals signs recorded in the clinical record after this time. 200 ml of NS bolus was also hung at that time with 150 ml infused at 12:40 p.m.
-12:30 a.m.: RN called report to the RN at Hospital #2.
-12:40 a.m.: The RN gave report to the ambulance RN.
-12:50 a.m.: The RN documented the patient's blood glucose was 51 mg/dl, the physician was notified, orders received and pharmacy notified.
-1 a.m.: The RN documented "NC" in all sections of her reassessment of the patient except the patient had "(+) stool" at that time.
-1:15 a.m.: The RN documented the ambulance RN reported: "...Dextrose will not flow into IV. Rechecked pts IV & IV noted to have been discontinued (with) catheter intact. MD notified & will give pt oral glucose in mean time. (Name of ambulance) RN will attempt to start another IV."
-1:40 a.m.: The physician wrote an order for Oral glucose 10 gm by mouth.
-1:45 a.m.: The RN documented the ambulance RN was unable to start a new IV site and, "...pt took & tolerated oral glucose well (with) no emesis."
-2 a.m.: The RN documented the patient was in a car seat on the ambulance stretcher and transported to Hospital #2.

The EMTALA Consent/Transfer/Certification Form dated "1-5-09" (sic) at "2330" (11:30 p.m.) included a section for the ED physician to document the patient's condition at the time of transfer. There was an "X" in the box for the statement "Stable for transfer: No material deterioration of the patient's medical condition is likely, within a reasonable medical probability, to result from or occur during transfer." The "Risk of Transfer" section was not completed. The "Benefits of Transfer" section included an "X" in the box next to the statement, "Availability of higher specialized level of Pediatric ICU care (e.g. trauma, NICU)."

The physician's Emergency Documentation dictated on 1/5/2010 at 11:37 p.m. included the following: "HISTORY OF PRESENT ILLNESS: The child woke up with fevers and vomiting. He has been vomiting all day. He has not been able to hold any fluids down. He has been sleeping all day. He has been fussy. The mom has been trying to encourage him to drink, but he will not drink. At approximately 1830 p.m., he started developing a rash on his extremities. Mom then became very concerned about the rash and brought him straight to the E.D. There has been no diarrhea. There has been no ear pulling...REVIEW OF SYSTEMS: He is having fevers, chills, vomiting, fussiness, rash, sleepiness. The rest of the review of systems is unremarkable...PHYSICAL EXAM: VITAL SIGNS: Normal except for an elevated heart rate of 172 and an elevated respiratory rate at 36. GENERAL: This is an 11-month-old white male, somnolent, and tired appearing, in mild to moderate distress. SKIN: Warm and dry with a purpuric rash covering his entire body including the face, arms, back, abdomen, legs. Slightly onto the palms. It is a nonblanching purple rash...ED COURSE: An IV was started and the child was given two 20 mL per kg boluses of normal saline for a total of 400 mL...The parents were consented for a spinal tap because the rash could be concerning for meningococcemia. A spinal tap was done to try to rule out meningitis. Lab tests came back showing low white blood cell count at 4.2, low platelets at 50, and a bandemia with 17% bands. Comprehensive metabolic panel showed a low glucose of 53, and the child was given glucose by IV at a dose of 1 gram/kg. The CO2 came back very low at 14. Spinal tap studies were unremarkable. Once these initial tests were back, the rash seemed to be getting worse. The child started to perk up a little bit after the fluid boluses. I then called pediatrician at TMC to transfer the patient. Pediatrician that I spoke with was Dr. (name). She recommended that we start the patient in the pediatric intensive care unit and spoke with the pediatric intensivist Dr. (name), who accepted the the patient for transfer there. I ordered the child to be given dexamethasone 5 mg by IV, cefotaxime 550 mg by IV, and a third normal saline bolus with 200 ml by IV prior to transfer. A repeat Glucose showed that the Blood sugar was again 50. I ordered the patient to be given another 10 gm by IV but the child pulled the IV out. We were unable to establish another IV. 10 gram of oral glucose was given and ambulance personnel transported the child without an IV to the (name of Hospital #2) pediatric ICU...LAB TESTS: The complete blood count was normal except for a low white blood cell count of 4.2 and low platelets at 50. The differential showed elevated band neutrophils at 17% and elevated eosinophils at 2%. The CSF studies showed a colorless fluid with 5 red blood cells, 7 white blood cells, 100% mononuclear cells. CSF glucose was low at 35. The CSF protein was normal at 27.7. Coagulation studies show a high INR at 2.1 and a high PT at 18.6. Comprehensive metabolic panel showed a low glucose at 53, a high BUN at 33, low CO2 at 14...CLINICAL IMPRESSION: 1. Acute fevers and vomiting. 2. Dehydration. 3. Leukopenic. 4. Thrombocytopenia. 5. Bandemia. 6. Dehydration. 7. Purpuric rash of unclear cause. 8. Rule out meningococcemia." An "Addendum" to the Emergency Documentation dictated by the ED physician on 1/08/2010 at 12:55 a.m. included: "Tonight the patient's preliminary report of the spinal fluid cultures came back show 1+ Neisseria meningitidis beta lactamase negative. I was called by the lab to notify me of this. After reviewing the report, I called the Pediatric ICU at (name of Hospital #3). This is where the patient is currently located. I spoke with the patient's nurse...She asked to fax the report...and this was done. I asked her to please notify the PEDS ICU resident or attending. She said she would comply."

Patient #1's clinical records at Hospital #2 included a copy of the emergency medical personnel's documentation from the time of their arrival to Hospital #1 until their arrival time at Hospital #2. Documentation on their Patient Care Record revealed their unit was dispatched at "0000" (midnight) and arrived at Carondelet St. Joseph's Emergency Department at "0010" (12:10 a.m.). Documentation by the RN who completed and signed the form revealed the EMS unit was dispatched for "RN interfacility transfer" for a chief complaint of "Meningitis," and the Transport Reason was "PICU" (Pediatric Intensive Care Unit). The following vital signs were recorded:
<"UA (Upon Arrival)" BP 111/33; Pulse 190; Respirations 44; Oxygen saturation 98%
<"0140" (1:40 a.m.) BP 129/42; EKG "SVT" (Sinus Ventricular Tachycardia); Respirations 40; Oxygen saturation 96%.
<"0200" (2 a.m.) BP 88/52; EKG "SVT"; Pulse 202; Respirations 48; Oxygen saturation 95%.
<"0205" (2:05 a.m.) BP 115/53; EKG "SVT"; Pulse 198; Respirations 48; Oxygen saturation 98%.

Further documentation on the EMS Patient Care Record included: "0130 (1:30 a.m.)-IV infiltrated, DC. Unsuccessful to restart x 2 attempts, (Hospital #2) notified. 0150 (1:50 a.m.) Oral glucose 10 gm by SJH (St. Joseph's Hospital) RN. 0200 (2 a.m.)- SVT. Lethargic but MAE (moves all extremities), PERL (pupils equal reactive to light). SAO2-98%. Code 2 transfer, no changes enroute. Carried to bed. Report given, documents delivered, care transferred to PICU RN signing below." The EMS RN's assessment of the infant included: "Skin - mult purpura lesions all over body." The arrival to destination (Hospital #2) time was "0204" (2:04 a.m.).

Documentation by the PICU RN at Hospital #2 who received the patient included the following: "0205 (2:05 a.m.) Patient arrived from St. Joes into room...via stretcher. Mom and dad accompanied patient on transfer. Dr. (name) and Dr. (name) at bedside with RN assist. Pt alert with minimal response to stimulation. Fem (femoral) pulses palpable, but weak. Due to pt very poor perfusion, POX (pulse oxygen saturation) difficult to obtain, when attained POX 98-100% with accurate waveform, BP unatainable (sic). Pt arrived to unit with no IV access, one attempt by (name) RN. 0210 (2:10 a.m.) I/O (intraosseous) access established by Dr. (name). Pt prepared for intubation. Nimbex and versed given as ordered...0230 (2:30 a.m.): 4.5 ET (endotracheal) tube in place by Dr. (name) 12 at the teeth. Pt bradycardic to 70s at this time. Meds given as ordered...Pt bagged and HR increased to >100. 0245 (2:45 a.m.): Double lumen R IJ (right intrajugular) placed by Dr. (name). 0300 (3 a.m.) Double lumen R fem placed by Dr. (name). I/O access d/c. 0400 (4 a.m.): 8 fr Foley placed. 0430 (4:30 a.m.): Epi gtt (Epinephrine drip) started at this time. 0550 (5:50 a.m.): See code sheet."

The physicians' Pediatric History and Physical Examination dated 1/6/2010 at 2:50 a.m. at Hospital #2 included: "General Appearance: Lethargic, severe distress...Skin: Cool extremities, diffuse petechia, hemorrhagic purpura on all skin surfaces. Large bruise on (L) foot encompassing entire foot/ankle...Musculoskeletal: Slight movement of upper extremities...Neurologic: Sleepy, lethargic, occasional eye opening...Diagnosis #1: Septic Shock. Diagnosis #2: Purpura Fulminans Diagnosis #3: Resp Failure. Diagnosis #4: Mech Vent...Coagulopathy." The physician documented an Addendum in the Inter-Disciplinary Progress Record at 6:30 a.m. that included: "Pt w/ overwhelming Purpura Fulminans...Pt. intubated successfully after arrival...Pt. moribund on arrival. HR~ 200. No measurable BP during initial resuscitation. No palpable distal pulses. Fem pulse thready...Episode of sudden unexplained bradycardia @ 0600 likely related to critical acidosis, (low) calcium...Pt did receive ~ 90 ml/kg IVF (intravenous fluids) (NS) boluses pre-PICU...Episodes of hypoglycemia...Coagulopathy related to overwhelming sepsis. Replacing FFP, platelets, PRBC's...Death probable in this moribund patient w/refractory septic shock...."

Extensive documentation in Patient #1's clinical record revealed the patient continued to deteriorate in spite of aggressive care and treatment. The patient was transferred to Hospital #3 on or around 7:15 p.m. on 1/06/2010 for a higher level of care and treatment that included "ECMO" (Extracorporeal Membrane Oxygenation).

A review of Patient #1's clinical records from Hospital #3 revealed the patient was admitted on 1/06/2010. Again, in spite of continued aggressive care and treatment, the patient continued to decline and the decision was made to withdraw life support. The patient died on 1/10/2010.

A telephone interview was conducted on 4/6/10 with a staff member of Nursing Administration at Hospital #2. At the request of the surveyor, the staff member reviewed their internal documentation and reported the initial call from Carondelet St. Joseph's Hospital requesting transfer was received at 10:52 p.m. on 1/5/2010, and their pediatric intensivist was paged. The Nursing Administration Staff member stated a PICU bed was requested at 10:56 p.m., their pediatric intensivist contacted the ED physician and Carondelet St. Joseph's Hospital, and a specific PICU bed was assigned to the patient at 11:12 p.m.

The Chief Nursing Officer stated during an interview on 3/31/2010, that Patient #1's case came to the attention of hospital Administration when a public relations staff member was contacted by a local news station. Documentation provided by hospital administration confirmed they were contacted by a reporter for a local news station on 1/28/2010 that there were allegations of delay in treatment of the patient in the ED and subsequent death of the patient. The hospital initiated an internal investigation and the documentation included: "Following our review preliminary conclusions revealed timeliness of triage and treatment, appropriate care and transfer." However, because of the severity of the outcome, hospital administration conducted a more intensive investigation and review. Documentation provided to the surveyor by Hospital Administration revealed Physician #1 obtained a "2nd opinion" from another ED physician on duty at the time Patient #1 was in the ED. That physician reported during their interview that the: "Infant was not toxic looking, functioning fine...rash on trunk, purpura, none on buttocks or palms or soles, was limited to trunk...no fever...recommend lumbar puncture to differentiate between meningitis and Henock-Schonlein Purpura...."

The Hospital's investigation of the incident included a review of outside physician authored and published literature. Documentation provided to the surveyor by Hospital Administration included "Literature Review Summary - St. Joseph's Hospital - Emergency Department Meningococcemia Case...The purpose of the literature review and summary is to identify: Current evidenced based information about the topic being evaluated...." The Literature Review Summary included the following:

Reference Source: Rubin, D.H. et.al (2010) Rosen's Emergency Medicine: Concepts and Clinical Practice.
Title - Neurologic Disorders (Chapter 173).
Summary/Findings: "This chapter discusses acute bacterial meningitis and offers the following: Acute Bacterial Meningitis
- It is imperative to recognize subtle signs and symptoms of potential bacterial meningitis in infants and young children...
- Mortality rates for treated cases of acute bacterial meningitis are 20-30% in neonates and adults and 2% in infants and children.
- Beyond the neonatal period, S. pneumoniae and N. meningitides account for 90% of the documented cases of acute bacterial meningitis in the U.S.
- In 3/4 of children ultimately diagnosed with Acute Bacterial Meningitis, the clinical presentation is sub-acute, evolving over 2-5 days. If the child is examined early in the course, physical signs may be subtle or lacking.
- At the onset, affected children typically exhibit a variety of non specific S&S that are often seen in children with trivial self-limiting illnesses (e.g. fever, malaise, decreased interest in surrounds, irritability, alteration in sleeping pattern, anorexia, nausea, vomiting, or diarrhea).
- Usually children with this insidious presentation have a better prognosis than patients who present with rapid progression of S&S.
- Those that present with fulminant illness exhibit a higher risk for death or for both immediate and long term complications.
- As a rule, the younger the child, the more non specific and ambiguous the S&S.
- The cutaneous expression of acute bacterial meningitis may be a helpful finding suggestive of a specific organism (e.g. petechial and purpuric eruptions may suggest meningococcemia but can also be seen in pneumococcal disease and H. influenzae meningitis...."

Reference Source: Kaplan, S.L. (2009) UpToDate
Title: Epidemiology, clinical features and diagnosis of acute bacterial meningitis in children.
Summary/Findings: "This article details acute bacterial meningitis in children and offers the following:
- Suspected bacterial meningitis is a medical emergency and immediate diagnostic steps must be taken in order to establish the specific cause so that the appropriate antimicrobial therapy can be initiated.
-If untreated, the mortality rate for bacterial meningitis approaches 100%.
- Acute bacterial meningitis has 2 patterns of presentation a) develops progressively over one or several days and may be preceded by fever b) the course is acute and fulminant developing rapidly over several hours. The rapidly progressive form is frequently associated with brain edema...
-Petechiae and purpura is most commonly seen with N. meningitides and are usually more pronounced on the extremities and can be preceded by an erythematous maculopapular eruption...."

Reference Source: Raffini, L (2009). UpToDate
Title: Evaluation of purpura in children
Summary/Findings: This article offers the following:
"The evaluation of a child with purpura must combine speed and skill as purpura can be the initial sign of a life threatening meningococcal infection requiring immediate attention. The initial approach should be dictated by the general appearance of the child and the presenting vital signs...."

Reference Source: Javid, M.H. & Ahmed, S.H. (2009). Retrieved from e-medicine.medscape.com/article/221473-print on 2/11/2010
Title: Meningococcemia
Summary/Findings: "This article details the pathophysiology, frequency, clinical presentation, diagnosis, and treatment of meningococcemia. It offers the following information:
- The case fatality rate is approximately 10%.
- The mortality rate of fulminant infection remains high with most deaths occurring with 48 hours.
- One half of the deaths associated with shock, occur with the first 12 hours of hospitalization...."

Reference Source: Apicella M. (2009) UpToDate
Title: Diagnosis of Meningococcal Infection
Summary/Findings: "This article discusses the diagnosis of meningococcal infection and offers the following information:
- The gold standard for the diagnosis of systemic meningococcal infection is the isolation of N. Meningitides by culture (blood or CSF)...
- Antibiotic therapy should not be delayed pending performance of the LP...."

Reference Source: Claudius, I & Baraff, L.J. (2020) Emergency Medicine Clinics of North America. Vol 28, pp 67-84.
Title: Pediatric Emergencies Associated with Fever
Summary/Findings: "This article contributes the following:
- The hallmark of meningococcemia is the rash. Non-blanching hemorrhagic skin lesions that is more prominent on the extremities. The purpuric rash may be preceded by a maculopapular rash and arthralgia.
- A febrile patient with a non-blanching petechial rash has an 11-15% chance of suffering from meningococcemia...."

Physician #1 who provided the primary care to Patient #1 in the ED on 1/5 and 1/6/2010 was not available for an interview. Interviews were conducted with Physician #2 and Physician #3 on 4/1/2010 at 12:30 p.m. Both physicians reported they were familiar with the investigation of the care of Patient #1 and stated standards of care were met. They both agreed that Physician #1 followed protocols and algorithms based on the patient's presentation and that the patient was treated and transferred to another hospital in a timely manner. They reported the patient did not present critically ill or septic and that the patient was stable at the time of transfer.

In summary, Patient #1 arrived in the Emergency Department of Carondelet St. Joseph's Hospital on 1/5/10 at 7:03 p.m. and was triaged by an RN at 7:20 p.m. The parents reported symptoms of fever, vomiting, and being "sleepy" all day as reported by the parent. The parent first noted a rash and bruising at 6:15 p.m. at which time she decided to bring the patient in. The RN documented the patient had a rash/purpura all over his body and his lips were pale. The vital signs obtained and documented at that time revealed the patient had a fever and had high heart and respiratory rates. The patient was evaluated by the ED physician on or around 7:31 p.m. The physician performed a lumbar puncture at 9:50 p.m. to collect cerebrospinal fluid which was sent to the lab. Hospital #2 was contacted requesting transfer of the patient on or around 10:52 p.m., over 3 hours after the patient's arrival. Hospital #2 accepted the patient and notified the Carondelet St. Joseph's ED physician on or around 11 p.m. The physician wrote orders for the intravenous antibiotic Cefotaxime and intravenous steroid Dexamethasone at 11:20 p.m, and the antibiotic was administered at 12:01 a.m. on 1/6/2010, approximately 5 hours after the patient arrived to the ED. EMS transport arrived at 12:10 a.m. to transport the patient to Hospital #2 for admission to the PICU. Nursing documentation in the ED records revealed the patient's condition was deteriorating: the patient was tachycardic, hypotensive, hypoglycemic with "critical" values, and the purpura larger in size and spreading to include the infant's tongue. Although the patient's condition was deteriorating, there were no vital signs recorded after 12:15 a.m., and the patient's intravenous access was lost and not able to be restarted. There was no documentation that an ED physician attempted to restart the IV prior to transfer. The EMS unit left Carondelet St. Joseph's Hospital at 2 a.m. on 1/6/10 and arrived at Hospital #2 on or around 2:05 a.m. Although the Carondelet St. Joseph's ED physician documented the infant was "Stable" at the time of transfer (documented on the EMTALA transfer form), both the nursing staff and physicians at Hospital #2 documented that at the time of arrival, the patient was "Lethargic...in severe distress...without an IV access...cool extremities, diffuse petechia, hemorrhagic purpura on all skin surfaces...Large bruise on (L) foot encompassing entire foot/ankle...heart rate around 200." Hospital #2 was unable to obtain a blood pressure at the time of admission, and the patient required immediate life saving treatment including intubation with ventilator assistance and placement of first an intraosseous vascular access and then central line intravascular access. The patient continued to deteriorate in spite of aggressive care and treatment and was transferred to Hospital #3 within 24 hours for a higher level of care that included ECMO. The patient died at Hospital #3 on 1/10/2010.