HospitalInspections.org

Based on review of medical records, policies, Idaho State law, and staff interviews, it was determined the hospital failed to report the potential abuse of a minor to the proper state authorities as per state law for 1 of 1 minor patient (Patient #2) who presented to the ED and verbalized concern of abuse. This had the potential to cause harm to a vulnerable minor. Findings included:

A hospital policy titled "Child, Adult, Disabled Person or Elderly Abuse, Spouse/Partner Abuse - Recognition and Reporting" was reviewed. The policy stated, "...If abuse is suspected of a pediatric patient, calls shall be placed to the Child Protective Services and the local law enforcement agency..." This policy was not followed.

Idaho Law, TITLE 16, JUVENILE PROCEEDINGS, CHAPTER 16, CHILD PROTECTIVE ACT, 16-1605, states, " REPORTING OF ABUSE, ABANDONMENT OR NEGLECT. (1) Any physician, resident on a hospital staff, intern, nurse, coroner, school teacher, day care personnel, social worker, or other person having reason to believe that a child under the age of eighteen (18) years has been abused, abandoned or neglected or who observes the child being subjected to conditions or circumstances that would reasonably result in abuse, abandonment or neglect shall report or cause to be reported within twenty-four (24) hours such conditions or circumstances to the proper law enforcement agency or the department. The department shall be informed by law enforcement of any report made directly to it... When the attendance of a physician, resident, intern, nurse, day care worker, or social worker is pursuant to the performance of services as a member of the staff of a hospital or similar institution, he shall notify the person in charge of the institution or his designated delegate who shall make the necessary reports." This State law was not followed.

Patient #2 was a 16 year old male who presented in the ED on 5/1/23 at 9:20 PM. A document titled "ED Note Nursing" stated, "patient came in with two friends who are also minors. patient initially stating that he feels unsafe at home and did not want to tell his parents he was in the ER because he was afraid of his parents beating him. [ED physician] also came out to talk with the patient and in the midst of trying to figure out if we legally needed the parents permission to treat him or not, the friend of the patient states that his mother is a nurse and she is asking them to go to (nearby acute care hospital) to be evaluated there. [ED physician] was talking with the patient and the friends and verified that they were going to take them to (nearby acute care hospital) for care. Patient then signed the LWBS form." There was no further documentation for Patient #2.

The form referenced, "Medical Screening Exam and Treatment Refusal Form," was signed, dated, and timed by Patient #2. There was no indication the parent or guardian was aware or involved. Additionally, the form did not have a mechanism to capture a minor's signature.

In an interview on 10/31/23, beginning at 3:15 PM, the ED Nurse Manager was asked if CPS had been notified per State law regarding Patient #2. He replied, "I don't see any documented."

In a phone interview on 11/1/23 beginning at 6:30 PM, the ED physician who spoke to Patient #2 was asked if he notified CPS per State law. He stated he did not.

The hospital failed to comply with Idaho State law regarding the mandatory reporting of potential abuse of a minor.

Based on review of records, ED logs, policy review, and staff interview, it was determined the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice for 3 of 24 Patients (#2, #8, and #9) who presented in the ED for care. This had the potential to negatively affect patients presenting to the hospital's ED. Findings included:

A hospital policy dated 2/2023 and titled, "Emergency: EMTALA Guidelines For Emergency Department Services" was reviewed. The policy stated, "All patients shall receive a medical screening examination (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic." Additionally, the policy states, " ...Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of his/her medical condition, he/she is legally unstable as per EMTALA. This policy was not followed. Examples included:

1. Patient #2 was a 16 year old male who presented in the ED on 5/1/23 at 9:20 PM. A document titled "ED Note Nursing" stated, "patient came in with two friends who are also minors. Patient initially stating that he feels unsafe at home and did not want to tell his parents he was in the ER because he was afraid of his parents beating him. [ED physician] also came out to talk with the patient and in the midst of trying to figure out if we legally needed the parents permission to treat him or not, the friend of the patient states that his mother is a nurse and she is asking them to go to (nearby acute care hospital) to be evaluated there. [ED physician] was talking with the patient and the friends and verified that they were going to take them to (nearby acute care hospital) for care. Patient then signed the LWBS form."

The form referred to as LWBS was reviewed for Patient #2. This form was titled "Medical Screening Exam and Treatment Refusal Form." This form was signed, dated, and timed by Patient #2, a minor. There was no mechanism to capture this was a minor signing the form.

In an interview on 10/31/23 beginning at 3:15 PM, the ED Nurse Manager was asked if this was acceptable Patient #2 signed the Medical Screening Exam and Treatment Refusal Form. He replied that Patient #2 was under 18, so he should not have signed the refusal for an MSE.

The hospital allowed Patient #2 to refuse an MSE after he presented to the ED.

2. Patient #8 was a 28 year old female who was brought into the ED by EMS after delivering a baby at home on 5/23/23.

A hospital incident report involving Patient #8 dated 5/23/23 was reviewed and stated, "pt was brought in by ems[sic] to IFCH ed[sic] after having her baby at home. Pt complaint was just giving birth bleeding and low platelets. Pt was in the ed[sic]and taken to (acute care hospital) labor and delivery was not seen by an ed[sic] physician for Medical screen."

The EMS report was requested for Patient #8. The EMS report was unable to be produced. It was unclear how the complaint of "low platelets" was determined.

On 10/31/23 beginning at 3:25 PM, the ED Nurse Manager was interviewed; he confirmed Patient #8 was not documented in the ED log and did not have an MSE. The ED Nurse Manager also confirmed the only documentation the hospital had of Patient #8 was the incident report.

3. Patient #9 was a 12 month old female who presented to the ED with parents for a chief complaint of diarrhea for 4 days.

Patient #9's medical record was reviewed for ED visit on 8/20/23 at 9:54 PM. Patient #9's medical record included a note on 8/20/23 documented by an ED Physician. The note included: "Pt experiencing diarrhea x4 days. Pt went to (local acute care hospital) yesterday (8/10/23) and was diagnosed with EHEC. Went back today to (local acute care hospital), got labs and NS. Pt's parents stated that she threw up after and described 'blood' in vomit, as well as stool." Additionally, the ED Physician note stated, "She does appear mildly volume depleted. We have started an IV. IV fluids been given. The child does have an overall excellent clinical appearance. We will have the patient return with parents tomorrow for recheck. The IV has been left in and we can rehydrate at that time if necessary."

Patient #9's medical record indicated that she was discharged 2 hours later at 11:56 PM.

Patient #9 returned to ED for second visit 20 hours later on 8/21/23.

Patient #9's medical record included a note on 8/21/23 documented by an ED triage RN at 8:12 PM which stated, "[ED physician] told them to come back today for rehydrations (sic)."

Patient #9's medical record was reviewed for the second ED visit on 8/21/23 at 8:12 PM. The ED note for this visit was documented by a PA and stated, "This is her third trip to the emergency department for recheck as they have been instructed to keep close watch on this due to the risk of hemolytic uremic syndrome. Her mom reports that she will drink water, but nothing with any sugar or nutrients." Additionally, the ED note stated, "The patient present[sic] to the emergency department with her parents for mandatory recheck of dehydration and E. coli ...On exam she appears very tired. She is ill-appearing, but not toxic...she will be rechecked tomorrow morning ...IV was left in place for recheck."

Patient #9 was discharged at 12:15 AM, approximately 4 hours after ED admission.

An article, "Misconceptions Regarding Hemolytic Uremic Syndrome", was accessed via the website www.acep.org on 11/2/23 (American College of Emergency Physicians). The article, dated July 25,2023 stated, "Misconception 6: HUS can be managed in the outpatient setting. Fact: Children diagnosed with HUS should be transferred to a pediatric facility to be evaluated by a pediatric nephrologist and hospitalized. Management is supportive and includes intravenous (IV) fluid hydration, blood pressure management, red blood cell transfusions, and dialysis... Hospitalization and close monitoring for dialysis needs is mandatory."

A hospital incident report dated 8/21/23 was reviewed and stated, "Pt had a total of 4 ED admissions within 3 days. On 4th admission pediatric charge [RN] was called and asked to assist in gaining access/blood work. Upon assessment of pt, [Pediatric charge RN] noted peripheral mottling, delayed capillary refill (4 seconds), and listlessness in the pt. An initial 20ml/bolus was running and pt family mentioned pt had been diagnosed with Shiga Toxin E.Coli. During IV start and blood obtainment, pt noted to have little to no fight. Once completed, [Pediatric charge RN] spoke with ED bedside RN who stated pt was most likely going to be admitted to the pediatric unit. [Pediatric charge RN] responded they would prepare a room and be ready for pt. [Pediatric charge RN] began to follow pt in preparation for admission. Once labs were resulted [Pediatric charge RN] called ED bedside RN to follow up on direction of pt care and suggested an additional 20ml/kg bolus, due to concern of HUS, shock, and renal injury. An additional 20ml/kg bolus was given. At this time, [Pediatric charge RN] was still anticipating admission for continued monitoring, resuscitation, and care. However, pt was then, shortly after, discharged home."

On 11/01/23 beginning at 9:40 AM, the Pediatric charge RN was interviewed about Patient #9. She confirmed she started an IV and was concerned about the lack of response from Patient #9. Pediatric charge RN also stated Patient #9, "didn't have any blood pressures taken in the ED (at IFCH)." The Pediatric charge RN stated she was anticipating Patient #9 being admitted either to the Pediatric floor or transferred to a hospital with a PICU. The Pediatric charge RN confirmed that she called the Pediatrician on-call to notify of the possible pediatric floor admission.

On 11/01/23 beginning at 10:00 AM the Pediatrician on-call the evenings of Patient #9's two ED visits was interviewed. The Pediatrician confirmed that Patient #9 should have been admitted to the hospital. The Pediatrician was unsure why she was not consulted on Patient #9. The Pediatrician confirmed that Patient #9 had concerning lab values. She also stated, "If the ED discharges a kid with an IV ...just don't. If you are telling them to come back, just admit them to peds."

On 11/01/23 beginning at 1:45 PM a request was made by surveyors to interview the PA who discharged Patient #9 on 8/22/23. The PA was not available for interview.

On 11/01/23 beginning at 1:45 PM the ED Physician for Patient #9 on 8/21/23 was interviewed via telephone. He was asked why Patient #9 was discharged with an IV. The ED Physician confirmed that the reason for the IV was for possible hydration the next day. The ED Physician also confirmed he did not consult with the on-call Pediatrician.

Patient #9's ED provider note from the out of state hospital from 8/22/23 at 4:43 AM was reviewed. The record indicated Patient #9 was seen approximately 4 hours after being discharged from IFCH (the drive time is about 3 hours and 10 minutes; 217 miles).

The ED physician note from the out of state hospital stated, "Patient is a previously healthy 12 month old female who presents for evaluation of STEC and lethargy. On 8/18/2023, patient developed diarrhea. The next day, parents noticed blood in the diarrhea. They took her into the primary care doctor who ran labs and diagnosed her with STEC. Over the next few days, patient went into the ER 4 times and received 3 different fluid boluses. Her status continued to worsen and she became increasingly lethargic. She has been intermittently febrile Tmax 100.8 F(Fahrenheit). She began vomiting and had 1 episode of bloody emesis. She is no longer taking anything by mouth except water. Pediatric hospitalist noticed that the patient has been discharged after receiving fluid boluses without additional work-up multiple times and encouraged them to come to [out of state hospital] for work-up." Additionally, the ED Physician note stated, "Given lethargy with likely early HUS will admit to PICU." Patient #9 was discharged 9 days later.

The hospital failed to provide stabilizing treatment for Patient #9.