HospitalInspections.org

Based on record review and interview, the facility failed to provide an appropriate medical screening examination to 1(#1) of 21 patients who presented in the emergency department (ED) on May 1, 2022.

Findings include:

Patient #1 was a 14-year-old male with a past medical history of Atrial Septic Defect (ASD) repair and was brought in by his mother for evaluation of acute onset spontaneous suprapubic abdominal pain. Patient #1 reported severe pain associated with nausea. This incident happened 5 minutes before arrival to the emergency room, with no preceding trauma, nausea, vomiting, fever, pain, or anything out of the ordinary reported by Patient #1. Patient #1 had been eating and drinking without difficulty before the pain started. Patient #1 had a history of spina bifida.

Patient #1 presented to the Emergency Department on May 1, 2022, with complaints of abdominal pain and numbness in his legs. The patient was noted to have hypertension. Patient #1 complained of, "abdominal pain and I can't feel my legs and jaws hurt".

A review of the Physician's #5 emergency room records dated May 1, 2022, revealed the following:

"A 14-year-old boy past medical history of Atrial Septal Defect (ASD) repair is brought in by his mom for evaluation of acute onset spontaneous suprapubic abdominal pain that he reports is severe and associated with nausea this happened 5 minutes prior to arrival with no preceding trauma nausea vomiting fever pain or anything out of the ordinary he has been eating drinking at baseline before pain.

Past Med, Surg, Social, Fam Hx
Social History
Hx Tobacco Use: No
Smoking Status: Never Smoker
Hx Smoking Exposure: No
Hx Alcohol Use: No
Hx Recreational Drug Use: No
Hx Substance Use Treatment: No
Additional Social Hx
Tetanus Status: Less Than 5 Years

Review of Systems
General Appearance: Moderate apparent distress, WD/WN
Eye Exam: EOMI, Normal inspection, PERRL
ENT: Normal ENT inspection, Oropharynx is clear, tm's clear bilaterally
Neck: Full range of motion, Non-tender, Trachea midline
Respiratory: Lungs clear, no accessory muscle use, no respiratory distress, Normal breath sounds Cardiovascular: Regular rate, rhythm
Abdominal: Soft non distended mild suprapubic tenderness to palpation
Extremities: Non-tender, Normal range of motion
Psych/Mental Status: Normal for age
Cranial Nerves: CN II - XII intact, PERRL
Motor/Sensory: No Motor Deficit,
Skin: No Rashes, Normal Color, Warm/Dry

CBC HG 12.3

Differential Diagnosis
Acute onset suprapubic pain not consistent with appendicitis or cholecystitis having bowel movements not consistent with bowel obstruction will get labs, control pain, and reassess.

Comment
Afebrile no leukocytosis no tachycardia not septic, pain improved with over-the-counter medications labs unremarkable Will discharge with return precautions.

Clinical Impressions
Abdominal pain"

A review of the medical screening provided by Physician #5 on May 1, 2022, revealed the medical exam was not complete. Patient #1 was having lower abdominal pain. The patient did not recievce a CT (computed tomography) of the abdomen given the findings of pain documented by emergency room Physician #5 on the exam. Also, the patient was complaining of numbness in the legs, and there was no neurological exam of the legs conducted. The patient had a history of spina bifida, but Physician #5 failed to address this information in the examination. The patient was hypertensive throughout the emergency room visit and there was no documented evidence that the blood pressure was addressed. Toradol was given for pain, but the pain medication did not affect the elevated blood pressure. Blood pressure remained elevated during the emergency room visit.

The patient was discharged home without a neurological exam of the legs, a CT of the abdomen and pelvis, or management/evaluation of his blood pressure. Vital signs: T 98.3 P 69, R 18, 02 sat 98%, BP 177/76.

Patient #1 was taken by his mother to a different emergency room the next morning (5/2/2022) and found to have an aortic dissection with cardiac arrest. Patient #1 expired on May 2, 2022.

An interview with Staff #10 on the afternoon of 9/26/2022 acknowledged Patient #1 was discharged home with a blood pressure of 177/76 and abdominal pain. There was no CT of the abdomen ordered and the numbness in the patient's legs was not addressed by Physician #5.