HospitalInspections.org

Based on review of the central log, medical records, coroner's report, on-call calendar, 7/5/19 timeline provided by the CNO (Chief Nursing Officer), Medical Staff Rules and Regulations, policies and procedures, tour of the facility, observations, staff interviews, personnel files, and credential files, it was determined that the facility failed to provide to provide stabilizing treatment as required ) within the facility's capabilities when the on-call physician failed to come in to the Emergency Department (ED) for several hours after being called to evaluate and provide further treatment as needed for one (1) of 20 sampled medical records when Patient #1 presented to the ED with flu and fever on 7/4/19.

Cross refer to A-2404, as it relates to failure of the on-call physician to provide further evaluation and treatment for an emergency medical condition.

Cross refer to A-2406, as it relates to failure to provide an appropriate medical screening examination.

Cross refer to tag A-2407 as it relates to failure to provide stabilizing treatment.

Cross refer to tag A-2409 as it relates to failure to provide an appropriate transfer.

Based on review of the Emergency Department Central Log, medical records, coroner's report, ambulance report, Physician On-Call Calendar, Emergency Medical Service report, timeline of event 7/5/19 , Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined the hospital failed to best meet the needs of an individual who was receiving services in the ED and required the services of the on-call Pediatric Hospitalist, when the on-call pediatrician failed to come to the Emergency Department (ED) for 1 (#1) of 20 sampled patients with an identified emergency medical condition. The On-Call Pediatric hospitalist did not appear in the emergency department to see Patient #1 during her second ED visit until 4 hours after multiple calls from the ED physician and ED nursing staff, by then patient #1's vital signs and medical condition had severely deteriorated.

Findings were:

Hospital Visit #2 for Patient #1

Review of the facility' s central log and Patient #1 ' s medical record revealed that patient #1 (6 years old) returned to the ED on 7/4/19 at 10:07 p.m. (approximately 15.5 hours after 1st visit) accompanied by her mother and extended family. Review of the 'Triage Clinical Assessment' revealed that RN EE triaged (refers to sorting sick people according to their need for emergency medical attention) Patient #1 at 10:11 p.m. Patient #1 ' s mother reported that the patient had been seen in the ED "last night for the same complaint and a fever". In addition, the mother reported that Patient #1 had been unable to keep any fluids down despite taking Zofran and that Patient #1 had been diagnosed with the flu earlier in the week. Vital signs at triage were: Temperature 98.5 taken orally, Heart rate 129, (abnormal), Respirations 22, Blood pressure 97/47. Continued review of the triage assessment revealed that Patient #1 was weak and had pale mucous membranes (lining of organs particularly in the digestive, respiratory and urinary systems). RN EE assigned Patient #1 an ESI (Emergency Severity Index -tool used in the ED based on the acuity of a patient's health care problems) level of 3 (ESI level three- multiple types of resources needed to treat). Patient #1's heart rate at 10:37 p.m. was 127 (abnormal) beats per minute. Further review of the record revealed Patient #1's ESI level changed to an ESI level of 2 (High risk of deterioration, or signs of a time-critical). The ED nurse documented "Immediate notification of ER (Emergency Room) MD (Medical Doctor) of this patient's arrival. MD Notified."

Review of the 'Emergency Physician Record 'revealed that ED Physician KK performed the MSE at 10:49 p.m. Review of Physician KK ' s physical examination revealed that Patient #1 appeared lethargic (tired), was in mild distress, had dry mucous membranes, was tachycardic, and had clammy (wet or sweaty) skin.

Review of 'Patient Orders 'revealed that the following were entered at 10:53 p.m.: start an IV (intravenous), obtain blood for laboratory tests, start IV and give 500 cubic centimeters (cc) of Normal Saline IV fluids, and administer Zofran (medication to treat nausea and vomiting) 4 mg IV.

Review of 'Patient Notes,',Physician Notes', and 'Physician Orders' revealed the following:
--7/4/19 11:12 p.m.- Patient #1 had an IV placed and started receiving IV fluids and received a dose of Zofran.
--7/5/19 12:00 a.m.- Staff attempted to draw blood for laboratory tests but were unsuccessful.
--7/5/19 1:56 a.m.- Blood was drawn for laboratory tests. A review of Patient #1 ' s ' Laboratory Results ' included the following abnormal labs:
----Granulocytes- (type of white blood cell, can be abnormal with infections) was 93.3% (normal was 35-60%).
----Polycyte- (type of white blood cell can be abnormal with infections) was 87% (normal was 35-60%).
----Lymphocytes-(type of white blood cell can be abnormal with infections) was 10% (normal was 40-65%).
----Creatine- (waste product produced by muscle cells, excreted in the kidneys) was 1.4 mg/dL (normal was 0-0.7 mg/dL).
----Carbon Dioxide- (a waste product, blood carries carbon dioxide to the lungs and it is expelled through breathing) was 15 mmol/L (normal was 18-27 mmol/L).
--7/5/19 2:17 a.m. and 2:28 a.m.- ' Emergency Physician Record 'revealed that laboratory results were reviewed by the ED Physician KK.
7/5/19 2:30 a.m.-Physician KK ordered: Give 500 cc of Normal Saline.
--7/5/19 2:35 a.m.-Physician Note 4 'revealed that Physician KK spoke with Patient #1 ' s mother at 2:35 a.m. and discussed the tests results and plan of care, Physician KK noted that the Mother agreed and understood.
--7/5/19 3:41 a.m.-Physician KK ordered: Give Benadryl by mouth.
--7/5/19 4:51 a.m.- IV fluids completed; patient sleeping without distress.
--7/5/19 5:15 a.m.-Physician KK ordered: Urine for urinalysis and chest x-ray.
--7/5/19 5:23 a.m.-Physician KK ordered: Give Tylenol by mouth.
--7/5/19 5:28 a.m.- Patient #1 ' s temperature was 101.7 (abnormal). Tylenol was given.
--7/5/19 5:30 a.m.-Physician KK ordered: Give Rocephin via IV.
--7/5/19 5:30 a.m.- Patient #1 went to x-ray. The chest x-ray results were normal.
--7/5/19 5:52 a.m.- Physician KK at Patient #1 ' s bedside.
--7/5/19 6:05 a.m.- RN PP noted that admission orders were received from the on-call pediatric Hospitalist MM. House Supervisor FF informed RN PP that all beds are full, Patient will remain in the ED (on page 2 of the physician order sheet indicated the patient was in "OBS" (observational status) and will plan to admit for further evaluation and care .' Continued review of ' Emergency Physician Record ' revealed a consult with on-call Pediatrician MM for admission was entered.
--7/5/19 6:10 a.m.-Physician KK ordered: Give Motrin by mouth.
--7/5/19 6:27 a.m.-Vital Signs Pulse 177 (abnormal); Respiratory-64 (abnormal); Pulse Oximeter -100% ... BP- Blank
7/5/2019 6:30 a.m.- Temperature 99.
--7/5/19 6:38 a.m.- RN PP notified Physician MM that Patient #1 ' s heart rate was 178. (abnormal) Continued review of the note revealed that Physician MM instructed RN PP to "watch patient" and that a physician would be in the ED to assess Patient #1 at 7:30 a.m.
--7/5/19 6:50 a.m.-Physician KK ordered: Start IV fluids.
--7/5/19 6:55 a.m.-Physician KK ordered: Blood for laboratory test.
--7/5/19 6:58 a.m.- RN HH documented that Patient #1 ' s heart rate was 190 (abnormal) beats per minute and that the patient was drowsy and agitated. RN HH noted that Patient #1 was moved to a room across from the nurse ' s station and that IV fluids were started.
--7/5/19 7:02 a.m. Blood Pressure 61/39 (abnormal)
--7/5/19 7:06 a.m.- Laboratory staff attempted to draw blood for tests but were unsuccessful.
--7/5/19 7:11 a.m.- Respiratory therapist was at Patient #1 ' s bedside.
--7/5/19 7:20 a.m.- RN HH wrote: "Peds (pediatric) Hospitalist paged".
--7/5/19 7:25 a.m.-Physician KK ordered: Finger stick for blood sugar.
--7/5/19 7:26 a.m.- Patient #1 was placed on oxygen ...2 liters/NC (Nasal Cannula)
--7/5/19 7:31 a.m.-Physician KK ordered: Give Tylenol by mouth.
--7/5/19 7:40 a.m.- RN PP wrote that Patient #1 ' s temperature was 104.1(Abnormal) degrees Fahrenheit taken rectally and that Ibuprofen was administered for the fever.
--7/5/19 7:41 a.m.--Physician LL ordered: Test for mononucleosis (also called Kissing disease, respiratory infection) and strep (infection caused by streptococcus bacteria, usually upper respiratory). The results were negative.
--7/5/19 7:51 a.m.- Physician MM (On-call Pediatric Physician)was notified by RN HH that Patient #1 was clammy, tachycardic, tachypneic (increased respirations), febrile, and had received IV fluids. Physician MM relayed that she would speak to the ED physician.
--7/5/19 8:08 a.m.- IV access was attempted using ultrasound guidance. Attempt was unsuccessful.
--7/5/19 8:26 a.m.-RN HH documented that Patient #1 ' s rectal temperature was 103.5 (Abnormal) degrees.
--7/5/19 8:33 a.m.- RN HH documented that Patient #1 had received a total of 600 cc of IV fluid and that the patient remained tachycardic and tachypneic and that additional IV fluids were started.
--7/5/19 8:39 a.m.-Physician LL entered the order for an Electrocardiogram (recording of the electrical activity of the heart). Physician LL had signed review of the electrocardiogram on 7/5/19 at 7:15 a.m. The results revealed that Patient #1 ' s heart rate was 182 beats per minute.
--7/5/19 8:42 a.m.- RN HH spoke with House Supervisor II about on-call pediatrician MM needing to assess Patient #1. Advised House Supervisor that Patient #1 ' s family had requested a transfer to another facility. House Supervisor informed RN HH that she would call Physician MM.
--7/5/19 8:45 a.m.- A message was left for Physician MM to call the ED.
--7/5/19 8:55 a.m.-A message was left for Physician MM ' s office manager to have Physician MM phone the ED.
--7/5/19 8:59 a.m.-Physician MM phoned the ED and relayed that she would be down to the ED to see Patient #1.
--7/5/19 9:00 a.m.-RN HH documented that Patient #1 was unable to urinate.
--7/5/19 9:00 a.m.-House Supervisor II attempted to draw Patient #1 ' s blood.
--7/5/19 9:05 a.m.-RN HH documented that Patient #1 was agitated and anxious and unable to lay still. RN HH noted that Patient #1's Heart rate was 186 (abnormal), respiratory rate was 64 (abnormal) breaths per minute, palms of hands were blue with blanching (skin appears whitish when blood flow is restricted). Patient #1 ' s mother was with her. RN HH notified Physician LL.
--7/5/19 9:36 a.m.- RN HH notified by the laboratory that blood needed to be re-drawn on Patient #1.
--7/5/19 9:58 a.m.- Patient #1 was assisted to bedpan but was unable to urinate.
--7/5/19 10:00 a.m.- Physician MM arrived to assess Patient #1. The on-call pediatric hospitalist did not come to the ED timely to provide further evaluation and treatment for the patient until 4 hours later; despite being notified by the ED physician and staff nurses of Patient #1's abnormal VS and her deteriorating medical condition.


--7/5/19 10:17 a.m.-Physician LL ordered: Give Tylenol by mouth.
--7/5/19 10:18 a.m.- Patient #1 ' s rectal temperature was 103.3 degrees and additional order for Tylenol was entered.

Review of page 2 of handwritten telephone orders received by RN PP from Physician MM (no date or time documented) revealed Patient #1 was to be admitted as an Observation Patient. RN PP noted that the orders were "continued" and included placing Patient #1 on respiratory and droplet isolation (used when patients have an infectious disease), strict fluid intake and output measurement, Tylenol and Motrin were to be alternated every three (3) hours as needed, and blood work was to be done at 7:00 a.m. Page 1 of the orders was not in the medical record.
Continued review of the medical record revealed a handwritten note by Physician LL written on 7/8/19 regarding Patient #1's 7/5/19 ED course of treatment revealed that she was notified of RN's concern that Patient #1 had a heart rate in the 160 ' s and respiratory rate in the 30 ' s. Physician LL wrote that Patient #1 had been admitted from the ED overnight with dehydration, flu, and urinary tract infection. Physician LL noted that Patient #1 was in the ED as a medical/surgical hold awaiting a bed. Physician LL documented that Patient #1 was alert, tired, tachypneic, tachycardic, and that the patient denied pain but complained of thirst and being cold. Physician LL ' s exam of Patient #1 revealed dry mucous membranes, lips dry, lungs without wheezes, hands cold to touch but abdomen and thighs hot. Orders were given for strep and mono tests, additional IV fluids and additional antipyretic (medicine to reduce fever). Continued review of the note revealed that Physician LL spoke with Physician MM on 7/5/19 (time not documented) and relayed the findings of Patient #1 ' s assessment. Physician MM informed Physician LL that she would be by shortly to assess the patient. Care was returned to admitting physician and orders were started. Continued review of Physician LL ' s handwritten note revealed that she (Physician LL) was called again regarding Patient #1 ' s family's concerns that the patient's hands were ' turning purple .' Physician LL noted that she examined Patient #1 and found the patient's hands 'to be erythematous (superficial reddening of the skin), warmer ' . Physician LL noted that she explained to Patient #1 ' s family that the IV fluids were helping. Physician LL noted that Patient #1 was alert and had a capillary refill (time it takes for blood to recirculate after restricted) of 3 to 4 seconds (normal was 2-3 seconds). Physician LL advised RN DD to limit visitors. Physician LL observed Physician MM enter Patient #1 ' s room. Physician MM informed Physician LL that Patient #1 was to be transferred due to dehydration, fever, and sustained tachycardia. Physician LL agreed with Physician MM ' s plan of care. Physician LL documented ' these findings were recorded on 7/8/19 in recollection of events. The Patient was inpatient status during my exam. '





Review of 'Assessment/Treatments 'and 'Patient Notes 'revealed the following vital signs:
Date/Time Temperature Heartrate Respirations Blood Pressure Oxygen Saturation
7/4/19 10:11 p.m. 98.5 129 22 97/47
7/4/19 10:37 p.m. 127 22
7/4/19 10:56 p.m. 64/35
7/4/19 11:07 p.m. 129 28
7/4/19 11:37 p.m. 129 26
7/5/19 12:07 a.m. 128 27
7/5/19 12:37 a.m. 114 43
7/5/19 1:07 a.m. 124 40
7/5/19 1:37 a.m. 131 30
7/5/19 1:57 a.m. 93/59
7/5/19 2:27 a.m. 132 51
7/5/19 2:56 a.m. 98/66
7/5/19 2:57 a.m. 138 36
7/5/19 3:25 a.m. 89/26
7/5/19 3:27 a.m. 147 26
7/5/19 3:56 a.m. 97.7 128/107
7/5/19 3:57 a.m. 137 54
7/5/19 4:25 a.m. 93/52
7/5/19 4:27 a.m. 135 54
7/5/19 4:57 a.m. 154 22
7/5/19 5:28 a.m. 101.7
7/5/19 5:57 a.m. 172 26
7/5/19 6:27 a.m. 177 64 100% placed on oxygen
7/5/19 7:02 a.m. 61/39
7/5/19 7:58 a.m. 176 56 95%
7/5/19 8:28 a.m. 167 51
7/5/19 8:30 a.m. 103.5
7/5/19 8:58 a.m. 180 100%
7/5/19 9:02 a.m. 88/50
7/5/19 9:12 a.m. 103.5
7/5/19 9:28 a.m. 185 61 97%
7/5/19 9:58 a.m. 177
7/5/19 10:16 a.m. 103.3
7/5/19 10:28 a.m. 179 28 95%
7/5/19 10:58 a.m. 187 62 95%
7/5/19 11:22 a.m. 103.5 85/46
7/5/19 11:28 a.m. 181 55 94%

A review of a telemetry (recording of cardiac activity) strips on 7/5/19 revealed the following abnormalities:
--6:41:27 a.m. revealed that Patient #1 ' s heart rate was 190 beats per minute and respiratory rate was 70 breaths per minute. Oxygen saturation was 68%.
--6:41:39 a.m. revealed that Patient #1 ' s heart rate was 176 beats per minute and respiratory rate was 69 breaths per minute. Oxygen saturation was 88%.
--7:00:26 a.m. revealed that Patient #1 ' s heart rate was 189 beats per minute and respiratory rate was 41 breaths per minute.
--8:31:09 a.m. revealed that Patient #1 ' s heart rate was 175 beats per minute and respiratory rate was 59 breaths per minute. Oxygen saturation was 91%.

Review of a History and Physical completed by Physician MM dictated on 7/5/19 at 11:08 a.m. revealed Patient #1 was an admission from the ED now being transferred to an acute care hospital for dehydration, fever, influenza, and urinary tract infection. Physician MM noted that Patient #1 ' s mother had expressed a desire to transfer the patient to a higher level of care. Physician MM ' s physical exam of Patient #1 included review of vital signs, and noted that the patient was alert, awake, and in mild distress. Physician MM further noted that Patient #1 appeared as though she did not feel well but was not lethargic, that the patient responded and cooperated with the examination. Physician MM noted that Patient #1 was tachycardic, lungs clear, hands and feet acrocyanotic (bluish or purplish hands and feet caused by poor circulation), cool and clammy but with good pulses in wrists and ankles. Physician MM noted that her assessment included tachycardia most likely due to fever or secondary to dehydration, increased respiratory rate most likely due to current illness but will continue to monitor. Physician MM noted that Patient #1 was receiving IV fluids and did not have any current complaints of nausea and that another dose of Rocephin was to be administered per the receiving hospitals request. Physician MM noted that the acute care hospital had accepted Patient #1 and that the patient would be transferred there. Physician MM noted that she updated Patient #1 ' s mother.


Review of Crisp County emergency medical services (EMS) report revealed that EMS was dispatched to the facility to transport Patient #1 to Hospital B at 11:28 a.m. At 11:50 a.m. Patient #1's heart rate was 175, respirations were 24 beats per minute, oxygen saturation was 94 %, blood pressure was 114/57. At 12:10 p.m. Patient #1's heart rate was 181, respirations were 24, oxygen saturation was 97%, blood pressure was 116/55. At 12:38 p.m. Patient #1's heart rate was 186, respirations were 24, oxygen saturation was 96 %, blood pressure was 84/27. Review of the narrative revealed that Patient 1's skin was cool to touch, and no distress was noted. Patient #1 was on a cardiac monitor during transport. Rocephin IV was completed during transport and IV fluids were re-started. Patient #1 arrived at Hospital B at 12:41 p.m. and there were no changes noted enroute.

The medical record from the hospital (Hospital B) where Patient #1 was transferred to was reviewed. The review revealed that Patient #1 arrived at Hospital B on 7/5/2019 at 1250 p.m. via ambulance and the family was present.

The History and physical Consult notes- Discharge Summary dated 7/5/2019 at 2:27 p.m. was reviewed. The physician documented that patients chief compliant was fever, dehydration and urinary tract infection. Further review revealed in part, "History of Present illness, patient is a 6 year old female transferred from Crisp Regional Medical Center for Urosepsis (is when an infection moves from the urinary tract into the bloodstream) ...the course of her stay at Crisp is as follows: Vitals ranged from temperature 96.5 to 103 F (Fahrenheit) last one at transfer being 103.3, HR 114-185, last one at transfer being 178, RR-22-64, last one at transfer being 28, BP Systolic 61-128, last one at transfer being 88, Diastolic 26-107, last one being 50, SP02- 65-100, last one at transfer being 65 ...Impression and plan ...upon arrival patient was assessed and found to have poor perfusion, she was tachypneic and tachycardic. After labs she was noted to be Septic (infection in the blood stream, symptoms such as drop in blood pressure, increase in heart rated and fever). Patient was transferred to PICU (Pediatric Intensive Care Unit) service for possible Septic Shock ...Patient was found to have worsening tachypnea, tachycardia and perfusion ...Upon arrival to PICU access was obtained ... Stat labs and imagining were performed x2 NS (Normal Saline) bolus and sodium bicarbonate were given ...Patient was intubated and sustained brief period of CPR ([cardiopulmonary resuscitation) ...Patient was resuscitated prior to transfer to Hospital C. Prior to discharge Patient has received 2 units of PRBC (Packed Red Blood Cells), 3 units of FFP (Fresh Frozen Plasma), Sodium Bicarbonate x4, Calcium x2, Vancomycin and Meropenemx1 (medications used to treat infections) ... Aggressive resuscitative measures continued family was at the bedside and were given updates on (Patient's) situation constantly, her extremely poor outcomes and progress was described. "A review of Facility B's transfer form revealed that Patient #1 was accepted at Hospital C for transfer on 7/5/2019 at 7:30 P.M. The patient was transported to Hospital C via hospital B critical care transport PICU.


Review of a faxed request from the County Coroner dated 7/8/19 revealed the Coroner had requested a copy of Patient #1's medical records. A requested copy of the County Coroner's report was received on 11/20/19. This report revealed Patient #1 was pronounced dead on 7/6/19 at 12:40 a.m. Hospital C ( a children's hospital (after arriving at the receiving hospital Patient #1 had been transferred from the receiving hospital to a children's hospital). The report indicated the cause of death was acute (sudden onset) hypoxiciema (below-normal level of oxygen in the blood) respiratory failure due to consequences of sepsis (infection of the blood stream resulting in symptoms such as drop in a blood pressure, increased heart rate, increased respirations, decreased urine output, fever, and chills) with multi-organ failure due to influenza A.

Review of the on-call calendar for July 2019 revealed that pediatric physician MM was on-call for the ED from 7/3/19 through 7/6/19.

The CNO provided a timeline for 7/5/19 which revealed the following:
--At 6:05 a.m., the on-call pediatrician MM gave telephone orders to admit Patient #1.
--The Medical Surgical (MS) 2 South Unit had 29 beds with a census of 29 patients and was staffed with six (6) nurses and three (3) technicians.
--MS 2 North Unit was closed/not staffed due to census.
--ICU had 15 beds with a census of 14 patients and was staffed with five (5) nurses and one (1) technician.

Review of the Medical Staff Rules and Regulations, approved 9/11/18, revealed the following:
4.1 COVERAGE
4.1.1 All physicians of the facility's Medical Staff, active category, who have an office for the practice of medicine within this area and who are less than 60 years old must take emergency specialty call on a rotation basis as established by the medical staff.

Review of facility policy entitled "Scope of Service in the Emergency Department " , policy number 6620155, last approved 7/2019, An on-call list of specialist physicians is maintained to assist in stabilizing patients. All necessary definitive treatment will be given to the patient within the hospital's capabilities. ED patients are then evaluated for response to treatment and are admitted or transferred for further treatment not provided by the hospital.

During an interview on 11/20/19 at 2:00 p.m. in the Conference Room, ED physician LL confirmed that she is the ED Medical Director. ED physician LL confirmed that that her shift on 7/5/19 started at 7:00 a.m. She explained that when her shift began Patient #1 had already been admitted but was being held in the ED until a bed on the MS 2 South Unit was available. ED physician LL said that she gave some orders because the nurses were concerned about Patient #1's elevated heart rate and respiratory rate. ED physician LL said she did not remember whether Patient #1 was on oxygen. ED physician LL said she felt Patient #1's legs to check for a rash and the child's legs felt warm. She said she then ordered a rectal temperature and "I believe" the rectal temperature was 104.0 degrees Fahrenheit. ED physician LL said she then asked the nurse to administer Tylenol for the elevated temperature. ED physician LL said Patient #1 appeared to be sick when she saw the patient but did not appear to be deathly ill. ED physician LL said there should have been an electronic order entered to admit the patient when ED physician KK spoke with the on-call pediatric physician MM. ED physician LL said the on-call pediatrician MM facilitated the transfer to the receiving facility. ED physician LL confirmed that the facility does not have a pediatric unit or pediatric intensive care unit. ED physician LL said pediatric patients can be admitted to the facility's intensive care unit. ED physician LL said the decision to admit to the intensive care unit would be at the discretion of the admitting physician. ED physician LL said that she has reviewed Patient #1's medical records for both visits on 7/4/19 and that the care was appropriate for the ED, she went on to explain that Patient #1 was admitted because the patient wasn't deemed well enough to go home.

During an interview on 11/20/19 at 2:45 p.m. in the Conference Room, RN FF confirmed that she is one (1) of the facility's Overhouse Supervisors (OHS). RN FF said she was the OHS on 7/4/19 when Patient #1 was brought into the ED the second time. RN FF said she was notified by the ED because they could not get an intravenous line started on Patient #1. RN FF confirmed that Patient #1 had been stuck several times and that she was able to start an intravenous line in the child's right shoulder area. RN FF reported that when she saw Patient #1 the patient was lethargic, did respond when spoken to, but did not cry out when stuck. RN FF said Patient #1 appeared sick, but that she did not observe Patient #1 vomiting. RN FF explained that when she saw Patient #1 the plan was to admit the patient to the MS 2 South Unit. RN FF said she occasionally gets involved if the on-call physician has been called several times and has not responded. RN FF confirmed that there had been no delay in physician MM's response to the ED. RN FF said that she left the facility after her shift ended somewhere around midnight and the plan at that time was for Patient #1 to be admitted. RN FF said Patient #1's mother and grandmother are both Certified Nursing Assistants (CNAs) and they both previously worked at this facility.

During an interview on 11/20/19 at 3:00 p.m. in the Conference Room, ED physician KK confirmed that he was on duty from 7:00 p.m. on 7/4/19 until 7:00 a.m. on 7/5/19. ED physician KK said he provided care for Patient #1 during her second visit to the ED. ED physician KK said the mother reported that the patient was having intermittent fever, was not as active, and was vomiting. Physician KK said that he re-evaluated Patient #1, ordered lab tests, and intravenous fluids. ED physician KK said that initially nothing stood out except flu and urinary tract infection symptoms. ED physician KK said he later spoke with the mother and she reported that Patient #1 looked a little better. ED physician KK said he decided to give Patient #1 a second bolus of fluids for hydration. ED physician KK said a little later Patient #1 spiked another fever, an elevated heart rate, and elevated respirations. ED physician KK said he didn't feel comfortable discharging Patient #1 and that he called and spoke with the on-call pediatrician MM. ED physician KK said that Patient #1's heartrate remained elevated and that he called the on-call pediatrician MM again. ED physician KK said that he and the on-call pediatrician MM agreed that Patient #1 should be admitted to treat the fever, administer fluids, and monitor the patient's response to treatment. ED physician KK said near the end of his shift Patient #1's heartrate was going up and ED physician LL came on duty. ED physician KK said when he left Patient #1 was still being held in the ED with plans to admit. ED physician KK confirmed that the on-call pediatrician MM did not come down to evaluate the patient and that he (ED physician KK) and the on-call pediatrician MM spoke by phone and the on-call pediatrician MM gave telephone orders to one (1) of the nurses. ED physician KK said that when he paged the on-call pediatrician MM she called right back. ED physician MM said that his shift ended at 7:00 a.m. and that Patient #1 was admitted around 6:30 a.m.

During an interview on 11/20/19 at 3:30 p.m. in the Conference Room, pediatrician MM explained that she has worked at the facility as a pediatrician for 11 years, since completing her residency. Pediatrician MM confirmed that she received a phone call from one (1) of the ED physicians (stated she was not sure which ED physician made the call) on 7/5/19 during Patient #1's second visit the ED. Pediatrician MM said that she received the call because she was the on-call pediatrician. Pediatrician MM said that she spoke with the ED physician and that the report she received sounded like Patient #1 had the flu with fever and dehydration. Pediatrician MM said it did not sound like Patient #1 was in acute distress, so she gave orders to admit Patient #1. Pediatrician MM said she believes the call came sometime during the middle of the morning because she was still at home. Pediatrician MM said she was called again regarding Patient #1 sometime prior to making rounds. Pediatrician MM said she informed the nurse to continue with the orders she had previously given and that Patient #1's primary care pediatrician should be making rounds soon. Pediatrician MM said that at some point she received another call and was informed that Patient #1's primary care pediatrician's office was closed, and that the patient's primary care pediatrician was out-of-town. Pediatrician MM said that she was asked if she could see Patient #1. Pediatrician MM said later she was on the unit seeing another patient when OHS II contacted her. Pediatrician MM said when she saw Patient #1 the patient was in some distress, was awake, alert, able to follow command, had an elevated heart rate, and elevated respirations. Pediatrician MM said that Patient #1's cranial nerves (nerves that relay information from the body to the brain) were intact and Patient #1 was moving all extremities. Pediatrician MM said that when she saw Patient #1 it was for an initial assessment around midmorning and that Patient #1 still had a fever and an elevated heartrate. Pediatrician MM said at that time she felt Patient #1 needed or might need a higher level of care. Pediatrician MM said she called the receiving hospital because Patient #1 had officially been admitted. Pediatrician MM said that she thought at the time she admitted Patient #1 that the facility would be able to provide the necessary care. Pediatrician MM said that Patient #1's condition changed and that she wrote orders for Patient #1 to be transferred to the receiving hospital. Pediatrician MM said she called and spoke with the accepting physician and she believes Patient #1 was to be admitted to a stepdown unit. Pediatrician MM said that dehydration, flu, and fever can cause elevated heartrate and elevated respirations.

During an interview on 11/20/19 at 3:50 p.m. in the Conference Room, Paramedic NN said he has been a paramedic for 28 years. Paramedic NN said that RN HH reported that the patient had purple colored hands and feet and that he did observe that the patient's hands were purple. Paramedic NN said Patient #1's oxygen saturation was 94-96% on oxygen at 2 liters. Paramedic NN explained that Patient #1's heartrate was around 170-180 beats per minute and respiration were around 24. Paramedic NN said he doesn't remember anything else about Patient #1.

During an interview on 11/20/19 at 4:00 p.m. in the Conference Room, Emergency Medical Technician (EMT) OO said she has been an EMT for four (4) years. EMT OO said she recalls Patient #1 and that RN II had reported that Patient #1's hands and feet were purple. EMT OO said she was riding up front in the ambulance and a new girl was driving. EMT OO said Patient #1 didn't feel hot, and that she asked if the patient still had a fever and RN II said yes. EMT OO said she doesn't remember anything else about Patient #1.

During an interview on 11/20/19 at 4:30 p.m. in the Conference Room, RN II confirmed that she is one (1) of the facility's Overhouse Supervisors (OHS). RN II confirmed that her shift on 7/5/19 began at 8:00 a.m. She said that the MS 2 South Unit has 31 beds but one (1) of the rooms is used as a physician dictation room and another is used to store linen, leaving 29 available beds. RN II said that on 7/5/19 the MS 2 South Unit had 29 patients and the MS 2 North Unit was closed. RN II said that the MS 2 North Unit is routinely closed due to census. RN II confirmed that in an emergency she and the MS 2 South Unit Charge Nurse would be available to open the MS 2 North Unit for any patients requiring admission. RN II said that on 7/5/19 she received report that Patient #1 was in the ED being held for an available MS 2 South Unit bed. RN II explained that MS 2 South Unit had a patient being discharged and that the room was to cleaned STAT (immediately). RN II said Patient #1 was to be admitted once the room was cleaned. RN II said she received a call from the ED that Patient #1's mother wanted to speak with the on-call pediatrician MM. RN II explained that she spoke with Patient #1's mother, called the on-call pediatrician MM, and that the on-call pediatrician MM spoke with Pati

Based on review of the central log, medical records, coroner's report, on-call calendar, 7/5/19 timeline provided by the CNO, Medical Staff Rules and Regulations, policies and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening (MSE) within the facility's capabilities when the on-call physician failed to come in to the Emergency Department (ED) for several hours after being called by the ED physician to evaluate and provide further treatment as needed for one (1) of 20 sampled medical records when Patient #1 presented to the ED with flu and fever on 7/4/19.

Findings were:

Visit #1
Review of the facility ' s central log revealed that Patient #1 arrived to the Emergency Department (ED) on 7/4/19 at 2:01 a.m. by private vehicle. Patient #1 was a six (6) year old child who was brought in to the ED by her mother.

Review of the medical record revealed Patient #1 was triaged (assessment by a registered nurse [RN] to determine the priority in which patients will be seen) and assigned an Emergency Severity Index (ESI) level (assigned to indicate how critical a patient is) of two (2) on 7/4/19 at 2:09 a.m. Patient #1 ' s vital signs at 2:06 a.m. were: Temperature 103.2 degrees (normal is 98.6 degrees Fahrenheit if taken orally and 99.6 degrees if taken rectally), Heart rate 148 beats per minute (normal is 70-120 beats per minute), Respiratory rate 22 breaths per minute (normal was 18-30 per minute), and Blood pressure 104/74 (normal was less than 105/67) (webmd.com). Patient #1 ' s mother reported a chief complaint of "Flu, unable to break fever". Patient #1 ' s mother provided the staff with a medical history that included a diagnosis of influenza type A on the day prior to this visit. Review of the assessment done at 2:12 a.m. revealed that all systems were within normal limits.

Continued review of the medical record revealed that a medical screening examination (MSE) was completed by ED Physician JJ at 2:14 a.m. Review of the physician ' s notes revealed that Patient #1 had been assessed at an Urgent Care Center one (1) day prior to this visit with a temperature as high as 105.3 and was diagnosed with influenza A. Patient #1 had been given Tamiflu (a medicine used to treat the flu) at the Urgent Care Center. Patient #1 ' s parent reported that her temperature at home remained high despite receiving Ibuprofen (medication used to treat fever). Review of Physician JJ ' s physical examination revealed that Patient #1 was alert, had normal peripheral pulses (pulses in arms and legs), was tachycardic (high heart rate), had skin that was ' very warm to touch ' and had normal skin color.

Review of the ' Patient Notes ' revealed that at 2:35 a.m., Patient #1 received oral Tylenol (medicine used for pain relief and to decrease temperature) for her fever but vomited afterward. An order was written for Zofran (medicine for nausea and vomiting) 4 milligrams (mg) for nausea at 2:35 a.m. Tylenol was given again by mouth at 3:17 a.m. At 3:23 a.m., orders were written for laboratory tests and a bag of normal saline (fluid for hydration) to be administered intravenously (IV insertion of a small plastic tube into a vein to administer medications and/or intravenous fluids). Patient #1 ' s vital signs at 3:53 a.m. were: Temperature 103.1 degrees Fahrenheit; Heart rate 122, Respirations 18, and Oxygen saturation (level of oxygen in the blood) 99% (normal 95-100%). At 4:29 a.m. an order was written for Rocephin 1 gram (antibiotic) IV to be administered. Patient #1 ' s vital signs at 4:44 a.m. were: Temperature 101.1, Heart rate 115, Respiratory rate 20, and Oxygen saturation: 99%.

Continued review of the record revealed that Patient #1 was able to take fluids without problems at 5:26 a.m. An order was written at 5:32 a.m. for Patient #1 to be discharged to home. The discharge diagnoses were: influenza type A, dehydration, and urinary tract infection. Discharge instructions included: completion of Tamiflu doses, Bactrim (antibiotic) by mouth, maintain hydration with fluids, popsicles and Pedialyte, and rotate Ibuprofen and Tylenol around the clock to control fever. In addition, instructions to return to the ED for persistent fever, vomiting, changes in mental status, inability to urinate, or for any other concerns. A prescription for Bactrim was given to the parent at discharge. At 5:34 a.m. Patient #1 ' s vital signs were: Temperature 100.2, Heart rate 119, Respiratory rate 20, and Oxygen saturation: 100%. At 5:59 a.m. Patient #1 ' s vital signs were: Temperature 102.4, Heart rate 122, Blood pressure 113/63, and Oxygen saturation: 100%. At 6:49 a.m. Patient #1 ' s vital signs were: Temperature: 100.6, Heart rate 129, Blood pressure 113/63, and Oxygen saturation: 100%. Patient #1 was discharged home with family at 6:49 a.m.


Visit #2
Review of the facility ' s central log and Patient #1 ' s medical record revealed that the patient presented to the ED on 7/4/19 at 10:07 p.m. accompanied by her mother and extended family. Review of the ' Triage Clinical Assessment ' revealed that RN EE triaged Patient #1 at 10:11 p.m. Patient #1 ' s mother reported that the patient had been seen in the ED "last night for the same complaint and a fever". In addition, the mother reported that Patient #1 had been unable to keep any fluids down despite taking Zofran and that Patient #1 had been diagnosed with the flu earlier in the week. Vital signs at triage were: Temperature 98.5 taken orally, Heart rate 129, Respirations 22, Blood pressure 97/47. Continued review of the triage assessment revealed that Patient #1 was weak and had pale mucous membranes (lining of organs particularly in the digestive, respiratory and urinary systems). The triage assessment was otherwise normal, and RN EE assigned Patient #1 an ESI of 3 (three). Patient #1 ' s heart rate at 10:37 p.m. was 127 beats per minute.

Review of the ' Emergency Physician Record ' revealed that Physician KK performed the MSE at 10:49 p.m. Review of Physician KK ' s physical examination revealed that Patient #1 appeared lethargic (tired), was in mild distress, had dry mucous membranes, was tachycardic, and had clammy (wet or sweaty) skin.

Review of "Patient Orders" revealed that the following were entered at 10:53 p.m.: start an IV, obtain blood for laboratory tests, start IV and give 500 cubic centimeters (cc) of Normal Saline IV fluids, and administer Zofran 4 mg IV.

Review of ' Patient Notes ' , 'Physician Notes', and 'Physician Orders' revealed in part the following:
.
--7/5/19 2:35 a.m.-Physician Note 4 ' revealed that Physician KK spoke with Patient #1 ' s mother at 2:35 a.m. and discussed the tests results and plan of care, Physician KK noted that the Mother agreed and understood.
--7/5/19 5:52 a.m.- Physician KK at Patient #1 ' s bedside.
--7/5/19 6:01 a.m.- RN PP noted that admission orders were received from the on-call pediatrician MM. House Supervisor FF informed RN PP that all available beds were occupied in the facility and Patient #1 was to remain in the ED until a bed became available.
--7/5/19 6:02 a.m. Physician KK documented 'Spoke with hospitalist, will plan to admit for further evaluation and care ' . Continued review of ' Emergency Physician Record ' revealed a consult with a Pediatrician for admission was entered.
--7/5/19 6:10 a.m.-Physician KK ordered: Give Motrin by mouth.
--7/5/19 6:38 a.m.- RN PP notified Physician MM that Patient #1 ' s heart rate was 178. Continued review of the note revealed that Physician MM instructed RN PP to ' watch patient ' and that a physician would be in the ED to assess Patient #1 at 7:30 a.m.
--7/5/19 6:50 a.m.-Physician KK ordered: Start IV fluids.
--7/5/19 6:55 a.m.-Physician KK ordered: Blood for laboratory test.
--7/5/19 6:58 a.m.- RN HH documented that Patient #1 ' s heart rate was 190 beats per minute and that the patient was drowsy and agitated. RN HH noted that Patient #1 was moved to a room across from the nurse ' s station and that IV fluids were started.
--7/5/19 7:06 a.m.- Laboratory staff attempted to draw blood for tests but were unsuccessful.
--7/5/19 7:11 a.m.- Respiratory therapist was at Patient #1 ' s bedside.
--7/5/19 7:20 a.m.- RN HH wrote: ' Peds (pediatric) Hospitalist paged ' .
--7/5/19 7:25 a.m.-Physician KK ordered: Finger stick for blood sugar.
--7/5/19 7:26 a.m.- Patient #1 was placed on oxygen.
--7/5/19 7:31 a.m.-Physician KK ordered: Give Tylenol by mouth.
--7/5/19 7:40 a.m.- RN PP wrote that Patient #1 ' s temperature was 104.1 degrees Fahrenheit taken rectally and that Ibuprofen was administered for the fever.
--7/5/19 7:41 a.m.--Physician LL ordered: Test for mononucleosis (also called Kissing disease, respiratory infection) and strep (infection caused by streptococcus bacteria, usually upper respiratory). The results were negative.
--7/5/19 7:51 a.m.- Physician MM was notified by RN HH that Patient #1 was clammy, tachycardic, tachypneic (increased respirations), febrile, and had received IV fluids. Physician MM relayed that she would speak to the ED physician.
--7/5/19 8:08 a.m.- IV access was attempted using ultrasound guidance. Attempt was unsuccessful.
--7/5/19 8:26 a.m.-RN HH documented that Patient #1 ' s rectal temperature was 103.5 degrees.
--7/5/19 8:33 a.m.- RN HH documented that Patient #1 had received a total of 600 cc of IV fluid and that the patient remained tachycardic and tachypneic and that additional IV fluids were started.
--7/5/19 8:39 a.m.-Physician LL entered the order for an Electrocardiogram (recording of the electrical activity of the heart). Physician LL had signed review of the electrocardiogram on 7/5/19 at 7:15 a.m. The results revealed that Patient #1 ' s heart rate was 182 beats per minute.
--7/5/19 8:42 a.m.- RN HH spoke with House Supervisor II about on-call pediatrician MM needing to assess Patient #1. Advised House Supervisor that Patient #1 ' s family had requested a transfer to another facility. House Supervisor informed RN HH that she would call Physician MM.
--7/5/19 8:45 a.m.- A message was left for Physician MM to call the ED.
--7/5/19 8:55 a.m.-A message was left for Physician MM ' s office manager to have Physician MM phone the ED.
--7/5/19 8:59 a.m.-Physician MM phoned the ED and relayed that she would be down to the ED to see Patient #1.
--7/5/19 9:00 a.m.-RN HH documented that Patient #1 was unable to urinate.
--7/5/19 9:00 a.m.-House Supervisor II attempted to draw Patient #1 ' s blood.
--7/5/19 9:05 a.m.-RN HH documented that Patient #1 was agitated and anxious and unable to lay still. RN HH noted that Patient #1's Heart rate was 186, respiratory rate was 64 breaths per minute, palms of hands were blue with blanching (skin appears whitish when blood flow is restricted). Patient #1 ' s mother was with her. RN HH notified Physician LL.
--7/5/19 9:36 a.m.- RN HH notified by the laboratory that blood needed to be re-drawn on Patient #1.
--7/5/19 9:58 a.m.- Patient #1 was assisted to bedpan but was unable to urinate.
--7/5/19 10:00 a.m.- Physician MM arrived to assess Patient #1.
--7/5/19 10:17 a.m.-Physician LL ordered: Give Tylenol by mouth.
--7/5/19 10:18 a.m.- Patient #1 ' s rectal temperature was 103.3 degrees and additional order for Tylenol was entered.
--7/5/19 10:51 a.m.- Physician MM notified RN HH that Patient #1 would be transferred to another facility and gave an order to administer Rocephin via IV and to increase rate of IV fluids.
--7/5/19 11:20 a.m.- RN HH gave report to the receiving facility ' s RN.
--7/5/19 11:27 a.m.- Emergency Medical Services (EMS) arrived at facility to transport Patient #1 to the receiving facility.
--7/5/19 11:35 a.m.-Physician MM ordered-Give Motrin by mouth.
--7/5/19 11:44 a.m.- RN HH documented that Patient #1 was clammy and had a respiratory rate of 54 breaths per minute and heart rate of 187 beats per minute. RN HH also noted that Patient #1 was receiving IV fluids and had been unable to urinate and that Patient #1's hands and feet were blue with blanching. RN HH noted that Physician MM assessed Patient #1.
--7/5/19 11:48 a.m.- Patient #1 ' s temperature was 103.1 degrees, heart rate was 181, respirations were 25 beats per minute, oxygen saturation was 95 %, blood pressure was 85/45. Report was given to EMS personnel and patient left the ED via stretcher enroute to an acute care hospital.

Review of page 2 of handwritten telephone orders received by RN PP from Physician MM (no date or time documented) revealed Patient #1 was to be admitted as an Observation Patient. RN PP noted that the orders were "continued" and included placing Patient #1 on respiratory and droplet isolation (used when patients have an infectious disease), strict fluid intake and output measurement, Tylenol and Motrin were to be alternated every three (3) hours as needed, and blood work was to be done at 7:00 a.m. Page 1 of the orders was not in the medical record.

Review of a History and Physical completed by Physician MM dictated on 7/5/19 at 11:08 a.m. revealed Patient #1 was an admission from the ED now being transferred to an acute care hospital for dehydration, fever, influenza, and urinary tract infection. Physician MM noted that Patient #1 ' s mother had expressed a desire to transfer the patient to a higher level of care. Physician MM ' s physical exam of Patient #1 included review of vital signs, and noted that the patient was alert, awake, and in mild distress. Physician MM further noted that Patient #1 appeared as though she did not feel well but was not lethargic, that the patient responded and cooperated with the examination. Physician MM noted that Patient #1 was tachycardic, lungs clear, hands and feet acrocyanotic (bluish or purplish hands and feet caused by poor circulation), cool and clammy but with good pulses in wrists and ankles. Physician MM noted that her assessment included tachycardia most likely due to fever or secondary to dehydration, increased respiratory rate most likely due to current illness but will continue to monitor. Physician MM noted that Patient #1 was receiving IV fluids and did not have any current complaints of nausea and that another dose of Rocephin was to be administered per the receiving hospitals request. Physician MM noted that the acute care hospital had accepted Patient #1 and that the patient would be transferred there. Physician MM noted that she updated Patient #1 ' s mother. The facility failed to ensure that on 7/5/2019 that Patient #1 received and appropriate Medical Screening Examination and stabilizing treatment as evidenced by the on-call pediatrician not coming to the ED in person until 4 hours later to provide further evaluation and treatment for the patient after multiple calls from the ED staff that the patient's condition was worsening and deteriorating. On 7/4/2019 the facility had the capability (On-call Pediatrician) to provide an appropriate MSE and stabilizing treatment prior to transferring patient #1 to Hospital B.

Continued review of Patient #1 ' s medical record revealed that a consent for transfer was signed by Patient #1 ' s mother on 7/5/19 at 11:27 a.m. Physician MM signed the form titled ' Physician Assessment and Certification ' on 7/5/19 and noted that Patient #1 had been stabilized such that within reasonable medical probability, no material deterioration of the patient ' s condition is likely to result from transfer. Document revealed that the receiving facility was had accepted the patient and that report had been given to the accepting physician. This form revealed copies of the medical record was sent to the receiving facility and that Patient #1 was to be transported via EMS. This form revealed the benefit of the transfer was for a "higher level of care" there were no risks of the transfer documented.

Review of the EMS report revealed that EMS was dispatched to the facility to transport Patient #1 to the acute care hospital on 7/5/19 at 11:28 a.m. At 11:50 a.m., Patient #1 ' s heart rate was 175, respirations were 24 beats per minute, oxygen saturation was 94 %, and blood pressure was 114/57. At 12:10 p.m., Patient #1 ' s heart rate was 181, respirations were 24, oxygen saturation was 97 %, and blood pressure was 116/55. At 12:38 p.m., Patient #1 ' s heart rate was 186, respirations were 24, oxygen saturation was 96 %, and blood pressure was 84/27. Review of the EMS narrative revealed Patient #1 ' s skin was cool to touch, and that no distress was noted. EMS documentation revealed Patient #1 was on a cardiac monitor and Rocephin IV was completed during transport and that IV fluids were re-started. Patient #1 arrived at the receiving hospital at 12:41 p.m. and EMS notes revealed there were no changes noted enroute.


Continued review of the medical record revealed a handwritten note by Physician LL written on 7/8/19 regarding Patient #1's 7/5/19 ED course of treatment revealed that she was notified of RN ' s concern that Patient #1 had a heart rate in the 160 ' s and respiratory rate in the 30 ' s. Physician LL wrote that Patient #1 had been admitted from the ED overnight with dehydration, flu, and urinary tract infection. Physician LL noted that Patient #1 was in the ED as a medical/surgical hold awaiting a bed. Physician LL documented that Patient #1 was alert, tired, tachypneic, tachycardic, and that the patient denied pain but complained of thirst and being cold. Physician LL ' s exam of Patient #1 revealed dry mucous membranes, lips dry, lungs without wheezes, hands cold to touch but abdomen and thighs hot. Orders were given for strep and mono tests, additional IV fluids and additional antipyretic (medicine to reduce fever). Continued review of the note revealed that Physician LL spoke with Physician MM on 7/5/19 (time not documented) and relayed the findings of Patient #1 ' s assessment. Physician MM informed Physician LL that she would be by shortly to assess the patient. Care was returned to admitting physician and orders were started. Continued review of Physician LL ' s handwritten note revealed that she (Physician LL) was called again regarding Patient #1 ' s family's concerns that the patient's hands were ' turning purple ' . Physician LL noted that she examined Patient #1 and found the patient's hands 'to be erythematous (superficial reddening of the skin), warmer ' . Physician LL noted that she explained to Patient #1 ' s family that the IV fluids were helping. Physician LL noted that Patient #1 was alert and had a capillary refill (time it takes for blood to recirculate after restricted) of 3 to 4 seconds (normal was 2-3 seconds). Physician LL advised RN DD to limit visitors. Physician LL observed Physician MM enter Patient #1 ' s room. Physician MM informed Physician LL that Patient #1 was to be transferred due to dehydration, fever, and sustained tachycardia. Physician LL agreed with Physician MM ' s plan of care. Physician LL documented ' these findings were recorded on 7/8/19 in recollection of events. The Patient was inpatient status during my exam. '





Review of facility policy entitled "Scope of Service in the Emergency Department", policy number 6620155, last approved 7/2019, revealed the hospital has eighteen (18) beds and provides service twenty-four (24) hours per day. The policy noted that one (1) purpose of the ED was to provide quality care for patients who arrive at the department regardless of time of arrival, patient ' s age, or ability to pay, in accordance with federal and state laws. This policy revealed all patients who present to the hospital for a non-scheduled visit seeking care shall receive an MSE by an ED provider. An on-call list of specialist physicians is maintained to assist in stabilizing patients. All necessary definitive treatment will be given to the patient within the hospital's capabilities. ED patients are then evaluated for response to treatment and are admitted or transferred for further treatment not provided by the hospital, or discharged, with follow up instructions as appropriate. Emergency care shall be delivered according to written policy and procedure and standard of care.



Review of facility policy entitled "EMTALA: (Transfer Policy and Medical Screening Exam)", policy number 4412266, last approved 1/2018, revealed the purpose was to establish clinical guidelines for MSE, stabilization, and safe appropriate transfer of patients to other facilities in compliance with EMTALA. This policy required any patient that presents to the ED or who developed an emergency medical condition (EMC) to be provided with an appropriate MSE. The MSE and stabilization shall be performed in accordance with EMTALA regulations.
DEFINITIONS OF TERMS:
--EMC: A medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in:
A. Placing the health of the individual in serious jeopardy
B. Serious Impairment of bodily functions, and
C. Serious dysfunction of any bodily organ or part.
--MSE: All patients must receive an MSE within the capabilities of the hospitals' DED to determine whether or not an EMC existed. The MSE nor the necessary stabilizing treatments shall be delayed in order to inquire about the individuals' method of payment, insurance status, or in order to obtain prior authorization. The MSE will not be delayed by the registration process.
A. The purpose of the MSE is the process required to reach, with clinical confidence, whether the individual has an EMC or not. The MSE is an ongoing process and it determines the needs for services (i.e., labs, x-rays, or other ancillary services) as well as the presence or absence of an EMC.

During an interview on 11/20/19 at 11:15 a.m. at the ED registration desk, Guest Service Technician (GST) CC explained that when a patient present with complaints of fever, hurting all over, or body aches they are asked to put on a face mask and the triage nurse is notified immediately. GST CC said that the triage nurse then takes the patient to the back as soon as possible.

During an interview on 11/20/19 at 2:00 p.m. in the Conference Room, ED physician LL confirmed that she is the ED Medical Director. ED physician LL stated she has worked at the facility for 15 years since completing her residency program. ED physician LL confirmed that that her shift on 7/5/19 started at 7:00 a.m. She explained that when her shift began Patient #1 had already been admitted but was being held in the ED until a bed on the MS 2 South Unit was available. ED physician LL said that she gave some orders because the nurses were concerned about Patient #1's elevated heart rate and respiratory rate. ED physician LL said she did not remember whether Patient #1 was on oxygen. ED physician LL said she felt Patient #1's legs to check for a rash and the child's legs felt warm. She said she then ordered a rectal temperature and "I believe" the rectal temperature was 104.0 degrees Fahrenheit. ED physician LL said she then asked the nurse to administer Tylenol for the elevated temperature. ED physician LL said Patient #1 appeared to be sick when she saw the patient but did not appear to be deathly ill. ED physician LL said there should have been an electronic order entered to admit the patient when ED physician KK spoke with the on-call pediatric physician MM. ED physician LL said the on-call pediatrician MM facilitated the transfer to the receiving facility. ED physician LL confirmed that the facility does not have a pediatric unit or pediatric intensive care unit. ED physician LL said pediatric patients can be admitted to the facility's intensive care unit. ED physician LL said the decision to admit to the intensive care unit would be at the discretion of the admitting physician. ED physician LL said that she has reviewed Patient #1's medical records for both visits on 7/4/19 and that the care was appropriate for the ED, she went on to explain that Patient #1 was admitted because the patient wasn't deemed well enough to go home.

During an interview on 11/20/19 at 2:45 p.m. in the Conference Room, RN FF confirmed that she is one (1) of the facility's Overhouse Supervisors (OHS). RN FF said she was the OHS on 7/4/19 when Patient #1 was brought into the ED the second time. RN FF said she was notified by the ED because they could not get an intravenous line started on Patient #1. RN FF confirmed that Patient #1 had been stuck several times and that she was able to start an intravenous line in the child's right shoulder area. RN FF reported that when she saw Patient #1 the patient was lethargic, did respond when spoken to, but did not cry out when stuck. RN FF said Patient #1 appeared sick, but that she did not observe Patient #1 vomiting. RN FF explained that when she saw Patient #1 the plan was to admit the patient to the MS 2 South Unit. RN FF said she occasionally gets involved if the on-call physician has been called several times and has not responded. RN FF confirmed that there had been no delay in physician MM's response to the ED. RN FF said that she left the facility after her shift ended somewhere around midnight and the plan at that time was for Patient #1 to be admitted. RN FF said Patient #1's mother and grandmother are both Certified Nursing Assistants (CNAs) and they both previously worked at this facility.

During an interview on 11/20/19 at 3:00 p.m. in the Conference Room, ED physician KK confirmed that he was on duty from 7:00 p.m. on 7/4/19 until 7:00 a.m. on 7/5/19. ED physician KK said he provided care for Patient #1 during her second visit to the ED. ED physician KK said the mother reported that the patient was having intermittent fever, was not as active, and was vomiting. Physician KK said that he re-evaluated Patient #1, ordered lab tests, and intravenous fluids. ED physician KK said that initially nothing stood out except flu and urinary tract infection symptoms. ED physician KK said he later spoke with the mother and she reported that Patient #1 looked a little better. ED physician KK said he decided to give Patient #1 a second bolus of fluids for hydration. ED physician KK said a little later Patient #1 spiked another fever, an elevated heart rate, and elevated respirations. ED physician KK said he didn't feel comfortable discharging Patient #1 and that he called and spoke with the on-call pediatrician MM. ED physician KK said that Patient #1's heartrate remained elevated and that he called the on-call pediatrician MM again. ED physician KK said that he and the on-call pediatrician MM agreed that Patient #1 should be admitted to treat the fever, administer fluids, and monitor the patient's response to treatment. ED physician KK said near the end of his shift Patient #1's heartrate was going up and ED physician LL came on duty. ED physician KK said when he left Patient #1 was still being held in the ED with plans to admit. ED physician KK confirmed that the on-call pediatrician MM did not come down to evaluate the patient and that he (ED physician KK) and the on-call pediatrician MM spoke by phone and the on-call pediatrician MM gave telephone orders to one (1) of the nurses. ED physician KK said that when he paged the on-call pediatrician MM she called right back. ED physician MM said that his shift ended at 7:00 a.m. and that Patient #1 was admitted around 6:30 a.m.

During an interview on 11/20/19 at 3:30 p.m. in the Conference Room, pediatrician MM explained that she has worked at the facility as a pediatrician for 11 years, since completing her residency. Pediatrician MM confirmed that she received a phone call from one (1) of the ED physicians (stated she was not sure which ED physician made the call) on 7/5/19 during Patient #1's second visit the ED. Pediatrician MM said that she received the call because she was the on-call pediatrician. Pediatrician MM said that she spoke with the ED physician and that the report she received sounded like Patient #1 had the flu with fever and dehydration. Pediatrician MM said it did not sound like Patient #1 was in acute distress, so she gave orders to admit Patient #1. Pediatrician MM said she believes the call came sometime during the middle of the morning because she was still at home. Pediatrician MM said she was called again regarding Patient #1 sometime prior to making rounds. Pediatrician MM said she informed the nurse to continue with the orders she had previously given and that Patient #1's primary care pediatrician should be making rounds soon. Pediatrician MM said that at some point she received another call and was informed that Patient #1's primary care pediatrician's office was closed, and that the patient's primary care pediatrician was out-of-town. Pediatrician MM said that she was asked if she could see Patient #1. Pediatrician MM said later she was on the unit seeing another patient when OHS II contacted her. Pediatrician MM said when she saw Patient #1 the patient was in some distress, was awake, alert, able to follow command, had an elevated heart rate, and elevated respirations. Pediatrician MM said that Patient #1's cranial nerves (nerves that relay information from the body to the brain) were intact and Patient #1 was moving all extremities. Pediatrician MM said that when she saw Patient #1 it was for an initial assessment around midmorning and that Patient #1 still had a fever and an elevated heartrate. Pediatrician MM said at that time she felt Patient #1 needed or might need a higher level of care. Pediatrician MM said she called the receiving hospital because Patient #1 had officially been admitted. Pediatrician MM said that she thought at the time she admitted Patient #1 that the facility would be able to provide the necessary care. Pediatrician MM said that Patient #1's condition changed and that she wrote orders for Patient #1 to be transferred to the receiving hospital. Pediatrician MM said she called and spoke with the accepting physician and she believes Patient #1 was to be admitted to a stepdown unit. Pediatrician MM said that dehydration, flu, and fever can cause elevated heartrate and elevated respirations.

During an interview on 11/20/19 at 3:50 p.m. in the Conference Room, Paramedic NN said he has been a paramedic for 28 years. Paramedic NN said that RN HH reported that the patient had purple colored hands and feet and that he did observe that the patient's hands were purple. Paramedic NN said Patient #1's oxygen saturation was 94-96% on oxygen at 2 liters. Paramedic NN explained that Patient #1's heartrate was around 170-180 beats per minute and respiration were around 24. Paramedic NN said he doesn't remember anything else about Patient #1.

During an interview on 11/20/19 at 4:00 p.m. in the Conference Room, Emergency Medical Technician (EMT) OO said she has been an EMT for four (4) years. EMT OO said she recalls Patient #1 and that RN II had reported that Patient #1's hands and feet were purple. EMT OO said she was riding up front in the ambulance and a new girl was driving. EMT OO said Patient #1 didn't feel hot, and that she asked if the patient still had a fever and RN II said yes. EMT OO said she doesn't remember anything else about Patient #1.

During an interview on 11/20/19 at 4:30 p.m. in the Conference Room, RN II confirmed that she is one (1) of the facility's Overhouse Supervisors (OHS). RN II confirmed that her shift on 7/5/19 began at 8:00 a.m. She said that the MS 2 South Unit has 31 beds but one (1) of the rooms is used as a physician dictation room and another is used to store linen, leaving 29 available beds. RN II said that on 7/5/19 the MS 2 South Unit had 29 patients and the MS 2 North Unit was closed. RN II said that the MS 2 North Unit is routinely closed due to census. RN II confirmed that in an emergency she and the MS 2 South Unit Charge Nurse would be available to open the MS 2 North Unit for any patients requiring admission. RN II said that on 7/5/19 she received report that Patient #1 was in the ED being held for an available MS 2 South Unit bed. RN II explained that MS 2 South Unit had a patient being discharged and that the room was to cleaned STAT (immediately). RN II said Patient #1 was to be admitted once the room was cleaned. RN II said she received a call from the ED that Patient #1's mother wanted to speak with the on-

Based on review of the central log, medical records, on-call calendar, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that stabilizing treatment was provided as required after the hospital's ED physician determined an emergency medical condition existed and further evaluation and treatment was needed emergently for one (1) of 20 (Patient #1) sampled medical records, whose condition when Patient #1 presented to the ED with flu and fever on 7/4/19.

Findings were:

Visit #2


Review of the ' Emergency Physician Record ' revealed that Physician KK performed the MSE at 10:49 p.m. Review of Physician KK ' s physical examination revealed that Patient #1 appeared lethargic (tired), was in mild distress, had dry mucous membranes, was tachycardic, and had clammy (wet or sweaty) skin.

Review of ' Patient Orders ' revealed I part, --7/5/19 6:01 a.m.- RN PP noted that admission orders were received from the on-call pediatrician MM. House Supervisor FF informed RN PP that all available beds were occupied in the facility and Patient #1 was to remain in the ED until a bed became available.
--7/5/19 6:02 a.m. Physician KK documented ' Spoke with hospitalist, will plan to admit for further evaluation and care ' . Continued review of ' Emergency Physician Record ' revealed a consult with a Pediatrician for admission was entered.
--7/5/19 7:51 a.m.- Physician MM was notified by RN HH that Patient #1 was clammy, brachycranic, tachypneic (increased respirations), febrile, and had received IV fluids. Physician MM relayed that she would speak to the ED physician.
--7/5/19 8:39 a.m.-Physician LL entered the order for an Electrocardiogram (recording of the electrical activity of the heart). Physician LL had signed review of the electrocardiogram on 7/5/19 at 7:15 a.m. The results revealed that Patient #1 ' s heart rate was 182 beats per minute.
--7/5/19 8:42 a.m.- RN HH spoke with House Supervisor II about on-call pediatrician MM needing to assess Patient #1. Advised House Supervisor that Patient #1 ' s family had requested a transfer to another facility. House Supervisor informed RN HH that she would call Physician MM.
--7/5/19 8:45 a.m.- A message was left for Physician MM to call the ED.
--7/5/19 8:55 a.m.-A message was left for Physician MM ' s office manager to have Physician MM phone the ED.
--7/5/19 8:59 a.m.-Physician MM phoned the ED and relayed that she would be down to the ED to see Patient #1.
--7/5/19 9:00 a.m.-RN HH documented that Patient #1 was unable to urinate.
--7/5/19 9:00 a.m.-House Supervisor II attempted to draw Patient #1 ' s blood.
--7/5/19 9:05 a.m.-RN HH documented that Patient #1 was agitated and anxious and unable to lay still. RN HH noted that Patient #1's Heart rate was 186, respiratory rate was 64 breaths per minute, palms of hands were blue with blanching (skin appears whitish when blood flow is restricted). Patient #1 ' s mother was with her. RN HH notified Physician LL.
--7/5/19 9:36 a.m.- RN HH notified by the laboratory that blood needed to be re-drawn on Patient #1.
--7/5/19 9:58 a.m.- Patient #1 was assisted to bedpan but was unable to urinate.
--7/5/19 10:00 a.m.- Physician MM arrived to assess Patient #1.

Review of a History and Physical completed by Physician MM dictated on 7/5/19 at 11:08 a.m. revealed Patient #1 was an admission from the ED now being transferred to an acute care hospital for dehydration, fever, influenza, and urinary tract infection. Physician MM noted that Patient #1 ' s mother had expressed a desire to transfer the patient to a higher level of care. Physician MM ' s physical exam of Patient #1 included review of vital signs, and noted that the patient was alert, awake, and in mild distress. Physician MM further noted that Patient #1 appeared as though she did not feel well but was not lethargic, that the patient responded and cooperated with the examination. Physician MM noted that Patient #1 was tachycardic, lungs clear, hands and feet acrocyanotic (bluish or purplish hands and feet caused by poor circulation), cool and clammy but with good pulses in wrists and ankles. Physician MM noted that her assessment included tachycardia most likely due to fever or secondary to dehydration, increased respiratory rate most likely due to current illness but will continue to monitor. Physician MM noted that Patient #1 was receiving IV fluids and did not have any current complaints of nausea and that another dose of Rocephin was to be administered per the receiving hospitals request. Physician MM noted that the acute care hospital had accepted Patient #1 and that the patient would be transferred there. Physician MM noted that she updated Patient #1 ' s mother.


Continued review of the medical record revealed a handwritten note by Physician LL written on 7/8/19 regarding Patient #1's 7/5/19 ED course of treatment revealed that she was notified of RN ' s concern that Patient #1 had a heart rate in the 160 ' s and respiratory rate in the 30 ' s. Physician LL wrote that Patient #1 had been admitted from the ED overnight with dehydration, flu, and urinary tract infection. Physician LL noted that Patient #1 was in the ED as a medical/surgical hold awaiting a bed. Physician LL documented that Patient #1 was alert, tired, tachypneic, tachycardic, and that the patient denied pain but complained of thirst and being cold. Physician LL ' s exam of Patient #1 revealed dry mucous membranes, lips dry, lungs without wheezes, hands cold to touch but abdomen and thighs hot. Orders were given for strep and mono tests, additional IV fluids and additional antipyretic (medicine to reduce fever). Continued review of the note revealed that Physician LL spoke with Physician MM on 7/5/19 (time not documented) and relayed the findings of Patient #1 ' s assessment. Physician MM informed Physician LL that she would be by shortly to assess the patient. Care was returned to admitting physician and orders were started. Continued review of Physician LL ' s handwritten note revealed that she (Physician LL) was called again regarding Patient #1 ' s family's concerns that the patient's hands were ' turning purple ' . Physician LL noted that she examined Patient #1 and found the patient's hands 'to be erythematous (superficial reddening of the skin), warmer ' . Physician LL noted that she explained to Patient #1 ' s family that the IV fluids were helping. Physician LL noted that Patient #1 was alert and had a capillary refill (time it takes for blood to recirculate after restricted) of 3 to 4 seconds (normal was 2-3 seconds). Physician LL advised RN DD to limit visitors. Physician LL observed Physician MM enter Patient #1 ' s room. Physician MM informed Physician LL that Patient #1 was to be transferred due to dehydration, fever, and sustained tachycardia. Physician LL agreed with Physician MM ' s plan of care. Physician LL documented ' these findings were recorded on 7/8/19 in recollection of events. The hospital failed to ensure that stabilizing treatment was provided as evidenced by the patient's (#1) condition deteriorated and was not stabilized prior to transfer; as the hospital was equipped with such staff services (on-call pediatric hospitalist), services (Intensive Care Unit-Pediatric- ), or equipment necessary to stabilize Patient #1's emergency medical condition on 7/4/2019. Additionally, the facility failed to follow their own policy and procedure as evidenced by failing to transfer Patient #1 on 7/4/2019 who was critically ill to the ICU for critical care nursing and stabilization. Further of the policy indicated that pediatric patients with deteriorating conditions were to be transferred to the service of pediatrician.

Policy and Procedure

A review of the policy titled, "Scope of Service in the Emergency Department" Policy Stat ID (identification) 6620155, origination date 09/1999, Last revised 09/2017 , Next Review 07/2021. Scope and Complexity of patient care needs, revealed in part, "An on-call list of physicians maintained to assist in stabilizing patients. All necessary definitive treatment will be given to the patient within the hospital's capabilities."


Review of facility policy entitled "ICU-Pediatric " , policy number 6575090, last approved 6/2019, revealed acutely or critically ill children after the newborn stage may be accepted in ICU for critical care nursing and stabilization. It was the policy of the unit that any pediatric patients that were not stable within 24 hours, or deteriorating conditions were to be transferred to the service of a pediatrician or to a facility specific for treatment of such patients. Parents were to be consulted as to the child ' s normal response for accurate evaluation and assessment of the patient. Any available ICU room may be used for the pediatric patient.

Interviews

During an interview on 11/20/19 at 2:00 p.m. in the Conference Room, ED physician LL confirmed that she is the ED Medical Director. ED physician LL stated she has worked at the facility for 15 years since completing her residency program. ED physician LL confirmed that that her shift on 7/5/19 started at 7:00 a.m. She explained that when her shift began Patient #1 had already been admitted but was being held in the ED until a bed on the MS 2 South Unit was available. ED physician LL said that she gave some orders because the nurses were concerned about Patient #1's elevated heart rate and respiratory rate. ED physician LL said she did not remember whether Patient #1 was on oxygen. ED physician LL said she felt Patient #1's legs to check for a rash and the child's legs felt warm. She said she then ordered a rectal temperature and "I believe" the rectal temperature was 104.0 degrees Fahrenheit. ED physician LL said she then asked the nurse to administer Tylenol for the elevated temperature. ED physician LL said Patient #1 appeared to be sick when she saw the patient but did not appear to be deathly ill. ED physician LL said there should have been an electronic order entered to admit the patient when ED physician KK spoke with the on-call pediatric physician MM. ED physician LL said the on-call pediatrician MM facilitated the transfer to the receiving facility. ED physician LL confirmed that the facility does not have a pediatric unit or pediatric intensive care unit. ED physician LL said pediatric patients can be admitted to the facility's intensive care unit. ED physician LL said the decision to admit to the intensive care unit would be at the discretion of the admitting physician. ED physician LL said that she has reviewed Patient #1's medical records for both visits on 7/4/19 and that the care was appropriate for the ED, she went on to explain that Patient #1 was admitted because the patient wasn't deemed well enough to go home.

During an interview on 11/20/19 at 2:45 p.m. in the Conference Room, RN FF confirmed that she is one (1) of the facility's Overhouse Supervisors (OHS). RN FF said she was the OHS on 7/4/19 when Patient #1 was brought into the ED the second time. RN FF said she was notified by the ED because they could not get an intravenous line started on Patient #1. RN FF confirmed that Patient #1 had been stuck several times and that she was able to start an intravenous line in the child's right shoulder area. RN FF reported that when she saw Patient #1 the patient was lethargic, did respond when spoken to, but did not cry out when stuck. RN FF said Patient #1 appeared sick, but that she did not observe Patient #1 vomiting. RN FF explained that when she saw Patient #1 the plan was to admit the patient to the MS 2 South Unit. RN FF said she occasionally gets involved if the on-call physician has been called several times and has not responded. RN FF confirmed that there had been no delay in physician MM's response to the ED. RN FF said that she left the facility after her shift ended somewhere around midnight and the plan at that time was for Patient #1 to be admitted. RN FF said Patient #1's mother and grandmother are both Certified Nursing Assistants (CNAs) and they both previously worked at this facility.

During an interview on 11/20/19 at 3:00 p.m. in the Conference Room, ED physician KK confirmed that he was on duty from 7:00 p.m. on 7/4/19 until 7:00 a.m. on 7/5/19. ED physician KK said he provided care for Patient #1 during her second visit to the ED. ED physician KK said the mother reported that the patient was having intermittent fever, was not as active, and was vomiting. Physician KK said that he re-evaluated Patient #1, ordered lab tests, and intravenous fluids. ED physician KK said that initially nothing stood out except flu and urinary tract infection symptoms. ED physician KK said he later spoke with the mother and she reported that Patient #1 looked a little better. ED physician KK said he decided to give Patient #1 a second bolus of fluids for hydration. ED physician KK said a little later Patient #1 spiked another fever, an elevated heart rate, and elevated respirations. ED physician KK said he didn't feel comfortable discharging Patient #1 and that he called and spoke with the on-call pediatrician MM. ED physician KK said that Patient #1's heartrate remained elevated and that he called the on-call pediatrician MM again. ED physician KK said that he and the on-call pediatrician MM agreed that Patient #1 should be admitted to treat the fever, administer fluids, and monitor the patient's response to treatment. ED physician KK said near the end of his shift Patient #1's heartrate was going up and ED physician LL came on duty. ED physician KK said when he left Patient #1 was still being held in the ED with plans to admit. ED physician KK confirmed that the on-call pediatrician MM did not come down to evaluate the patient and that he (ED physician KK) and the on-call pediatrician MM spoke by phone and the on-call pediatrician MM gave telephone orders to one (1) of the nurses. ED physician KK said that when he paged the on-call pediatrician MM she called right back. ED physician MM said that his shift ended at 7:00 a.m. and that Patient #1 was admitted around 6:30 a.m.

During an interview on 11/20/19 at 3:30 p.m. in the Conference Room, pediatrician MM explained that she has worked at the facility as a pediatrician for 11 years, since completing her residency. Pediatrician MM confirmed that she received a phone call from one (1) of the ED physicians (stated she was not sure which ED physician made the call) on 7/5/19 during Patient #1's second visit the ED. Pediatrician MM said that she received the call because she was the on-call pediatrician. Pediatrician MM said that she spoke with the ED physician and that the report she received sounded like Patient #1 had the flu with fever and dehydration. Pediatrician MM said it did not sound like Patient #1 was in acute distress, so she gave orders to admit Patient #1. Pediatrician MM said she believes the call came sometime during the middle of the morning because she was still at home. Pediatrician MM said she was called again regarding Patient #1 sometime prior to making rounds. Pediatrician MM said she informed the nurse to continue with the orders she had previously given and that Patient #1's primary care pediatrician should be making rounds soon. Pediatrician MM said that at some point she received another call and was informed that Patient #1's primary care pediatrician's office was closed, and that the patient's primary care pediatrician was out-of-town. Pediatrician MM said that she was asked if she could see Patient #1. Pediatrician MM said later she was on the unit seeing another patient when OHS II contacted her. Pediatrician MM said when she saw Patient #1 the patient was in some distress, was awake, alert, able to follow command, had an elevated heart rate, and elevated respirations. Pediatrician MM said that Patient #1's cranial nerves (nerves that relay information from the body to the brain) were intact and Patient #1 was moving all extremities. Pediatrician MM said that when she saw Patient #1 it was for an initial assessment around midmorning and that Patient #1 still had a fever and an elevated heartrate. Pediatrician MM said at that time she felt Patient #1 needed or might need a higher level of care. Pediatrician MM said she called the receiving hospital because Patient #1 had officially been admitted. Pediatrician MM said that she thought at the time she admitted Patient #1 that the facility would be able to provide the necessary care. Pediatrician MM said that Patient #1's condition changed and that she wrote orders for Patient #1 to be transferred to the receiving hospital. Pediatrician MM said she called and spoke with the accepting physician and she believes Patient #1 was to be admitted to a stepdown unit. Pediatrician MM said that dehydration, flu, and fever can cause elevated heartrate and elevated respirations.

During an interview on 11/20/19 at 3:50 p.m. in the Conference Room, Paramedic NN said he has been a paramedic for 28 years. Paramedic NN said that RN HH reported that the patient had purple colored hands and feet and that he did observe that the patient's hands were purple. Paramedic NN said Patient #1's oxygen saturation was 94-96% on oxygen at 2 liters. Paramedic NN explained that Patient #1's heartrate was around 170-180 beats per minute and respiration were around 24. Paramedic NN said he doesn't remember anything else about Patient #1.

During an interview on 11/20/19 at 4:00 p.m. in the Conference Room, Emergency Medical Technician (EMT) OO said she has been an EMT for four (4) years. EMT OO said she recalls Patient #1 and that RN II had reported that Patient #1's hands and feet were purple. EMT OO said she was riding up front in the ambulance and a new girl was driving. EMT OO said Patient #1 didn't feel hot, and that she asked if the patient still had a fever and RN II said yes. EMT OO said she doesn't remember anything else about Patient #1.

During an interview on 11/20/19 at 4:30 p.m. in the Conference Room, RN II confirmed that she is one (1) of the facility's Overhouse Supervisors (OHS). RN II confirmed that her shift on 7/5/19 began at 8:00 a.m. She said that the MS 2 South Unit has 31 beds but one (1) of the rooms is used as a physician dictation room and another is used to store linen, leaving 29 available beds. RN II said that on 7/5/19 the MS 2 South Unit had 29 patients and the MS 2 North Unit was closed. RN II said that the MS 2 North Unit is routinely closed due to census. RN II confirmed that in an emergency she and the MS 2 South Unit Charge Nurse would be available to open the MS 2 North Unit for any patients requiring admission. RN II said that on 7/5/19 she received report that Patient #1 was in the ED being held for an available MS 2 South Unit bed. RN II explained that MS 2 South Unit had a patient being discharged and that the room was to cleaned STAT (immediately). RN II said Patient #1 was to be admitted once the room was cleaned. RN II said she received a call from the ED that Patient #1's mother wanted to speak with the on-call pediatrician MM. RN II explained that she spoke with Patient #1's mother, called the on-call pediatrician MM, and that the on-call pediatrician MM spoke with Patient #1's mother and decided to transfer Patient #1 to another facility. RN II said that when she saw Patient #1 the patient was alert and asked to use the restroom. RN II said she helped Patient #1 with the bedpan but that the patient was unable to void. RN II confirmed that children can be admitted to the facility's intensive care unit but that an intensive care unit bed was not requested.

During an interview on 11/21/19 at 8:35 a.m. in the Conference Room, RN EE confirmed that he has been a RN since 1992 and has worked in the ED since 2006. RN EE said that he was the triage nurse on 7/3/19 from 6:00 p.m. to 6:00 a.m. on 7/4/19 and again on 7/4/19 from 6:00 p.m. to 6:00 a.m. on 7/5/19. RN EE confirmed that he triaged Patient #1 during both of the patient's visits on 7/4/19. RN EE reviewed the medical record and explained that on 7/4/19 during Patient #1's second visit the patient's vital signs were as follows: temperature 98.5, pulse 129, respirations 22, and blood pressure 97/47. RN EE said these vital signs were essentially normal for a six (6) year old. RN EE said Patient #1 had been treated earlier that day in the ED and returned due to continued fever, nausea, and not being able to keep anything down despite taking Zofran (medication used to treat nausea and vomiting). RN EE said he only saw Patient #1 while she was in triage and that the patient had remained stable while in triage. RN EE said that some pediatric patients are admitted but that it depends on the patient's symptoms and the pediatrician's orders. RN EE said that if a patient comes in with fever the first thing ED staff do is a flu swab, strep (type of bacteria) swab, respiratory syncytial virus (RSV - a common respiratory and lung infection in children) swab and ask the patient or family what the patient has been taking for the fever. RN EE said that ED staff then administer Tylenol or Motrin for a fever. RN EE said the ED secretary has the on-call list and if a consultation is ordered the ED secretary calls the hospital's front desk and the front desk clerk calls the on-call physician. RN EE said that once the on-call physician is on the line the ED physician is notified and the ED physician speaks directly with the on-call physician. RN EE said that he has never experienced an on-call pediatrician being asked to come in to the ED. RN EE said that the normal procedure is that the on-call physicians give their orders to the ED nurse by phone. RN EE said that the on-call pediatrician MM did come in and see Patient #1 and that physician MM wrote her orders at that time.

During an interview on 11/21/19 at 9:10 a.m. in the Conference Room, RN HH confirmed that she is an agency nurse and has been at the facility since March 2019. RN HH said she has been a RN for nine (9) years. RN HH reviewed the medical record for Patient #1's second visit and stated she remembers the patient. RN HH said that when she received report the patient looked extremely ill to her. RN HH said that she worked 7/5/19 and her shift began at 6:00 a.m. RN HH said Patient #1 had already been admitted when she got report and was being held in the ED until a room on the MS 2 South Unit was ready. RN HH explained that she had the patient moved closer to the nursing station so that the patient could be monitored closely. RN HH said she call the on-call pediatrician MM several times and the physician MM did not come in to see the patient. RN HH explained that some of the on-call physicians prior to going to the new computer system gave the ED nurses telephone orders and did not come in to see patients. RN HH said it depended on the physician and the time of day. RN HH explained that during the day the on-call physicians would come in and see patients but during the night the physicians gave telephone orders to the ED nurses. RN HH went on to explain that the new computer system does not allow the nurses to enter physician orders. RN HH said the on-call physicians have to enter their orders electronically. RN HH said the on-call physicians can enter their orders from home and don't necessarily have to come in to see the patient. RN HH said she had to call the OHS II because Patient #1's family was getting upset. RN HH said the OHS II went upstairs and found the on-call pediatrician MM in the nursery and informed the physician that Patient #1's family that the wanted to speak with her (pediatrician MM). RN HH said the OHS informed Patient #1's family that the on-call pediatrician MM would be there shortly. RN HH said pediatrician MM came down to see Patient #1 at 10:00 a.m. RN HH said that when she could not get the pediatrician, she asked ED physician LL to evaluate the patient even though the patient was already admitted. RN HH said physician LL ordered additional intravenous fluids. RN HH said she did a rectal temperature and administered Tylenol for Patient #1's fever. RN HH stated Patient #1's lips were dry, arms and legs were freezing, torso was burning up, and her hands and feet were blue and mottled. RN HH said pediatrician MM didn't think the child needed to be transferred. RN HH said she overheard pediatrician MM dictating that Patient #1 was stable for admission but that the family wanted the child transferred. RN HH said that once a patient is admitted the patient is under the care of the admitting physician and if something is needed the ED physician can be notified. RN HH said that when she called the pediatrician around 7:00 a.m., she was told that Patient #1 was to be seen by her primary care pediatrician. RN HH said physician MM called back once she determined that the patient's primary care pediatrician was out-of-town and told the nurse to continue the orders, she (physician MM) had previously given.

During an interview on 11/21/19 at 9:40 a.m. in the Conference Room, ED physician JJ confirmed that she has worked here full-time since October 2017 and prior to that she worked at another facility in the ED for 12 years. Physician JJ said she treated Patient #1 during the patient's first visit to the ED on 7/4/19 and that the patient's mother reported that the child had a positive flu swab at an Urgent Care Center. In addition, physician JJ said the mother reported that Patient #1 had received Tamiflu at the Urgent Care Center. Physician JJ said she believes the patient received an antibiotic, intravenous fluids, and Tylenol during the first ED visit. Physician JJ said Patient #1 looked good except for fever, the mother was concerned that she was unable to control Patient #1's fever and reported that the patient wasn't eating well. Physician JJ said the main concern was Patient #1's fever and a mild urinary tract infection. Physician JJ said she treated Patient #1 for flu, urinary tract infection, dehydration, and fever. Physician JJ said she gave instructions for medications and to follow-up with the patient's PCP, to rotate Tylenol and Motrin for the fever, to increase fluids, and to return to the ED if there were any change in condition. Physician JJ stated Patient #1 was discharged after eating crackers and drinking some juice and that she observed Patient #1 skipping when she left the ED. Physician JJ said she usually makes it clear as to whether she needs a phone consult or needs the on-call to come in to see the patient. Physician JJ said that if she feels she needs the on-call she has never had an on-call physician fail to come in when requested. Physician JJ said that the patient's temperature had gone down prior to discharge and that she kept the child for several hours so that she could ensure that her interventions had addressed the patient's presenting signs and symptoms. Physician JJ became emotional and said she was shocked when she learned that the patient had expired, stating she thought the child looked much better when she left after being treated during the first visit to the ED.

During an interview on 11/21/19 at 11:10 a.m. in the Conference Room, RN GG said that she worked at the facility for about four (4) years and is no longer employed. RN GG said that she left the facility after this incidence, explaining that Patient #1's death had been unexpected and that she had bonded with this child and the family. RN GG broke down in tears and said that she had even brought a meal in for the patient's sister. RN GG said she helped with triage and then took over the care of Patient #1 during the second ED visit. RN GG said her shift started at 6:00 a.m. on 7/5/19. RN GG said Patient #1 was very sick, sleepy, able to ambulate, talking, and her heartrate was elevated. RN GG said that at 6:00 a.m. Patient #1 was stable but definitely sick. RN GG started to cry and said, I told the mother Patient #1 was going to be alright which shows I didn't expect the outcome. RN GG explained that she was at home asleep when she received a call from a coworker to inform her that Patient #1 had took a turn for the worse and passed away at the other hospital. RN GG said the facility did a debriefing with counselors for the staff. RN GG stated she went to ED physician KK several times to express her concerns and that ED physician KK called the on-call pediatrician MM. RN GG said that she was not aware of any on-call physicians failing to respond to calls from the ED.

During a second interview on 11/21/19 at 12:55 p.m. in the Conference Room, pediatrician MM explained that on 7/5/19 her plan was to turn Patient #1 over to the patient's primary care pediatrician around 7:00 a.m. or 7:30 a.m. Physician MM explained that she thought her on-call coverage for Patient #1's was going to end at 7:00 a.m. Physician MM said she sent the primary care physician a text message to inform him that she was turning Patient #1 over to him at 7:00 a.m. Physician MM said that she did not talk to the primary care physician and when she didn't hear back from him, she checked and found out that the patient's primary care pediatrician's office was closed, and he was out-of-town. Physician MM said she usually is informed if Patient #1's primary care pediatrician's office is closed or if he is going out-of-town. Physician MM said that usually her office and Patient #1's primary care pediatrician's office are closed at the same time. When questioned as to whether she had considered any other diagnoses, Physician MM said that she did not think it was food poisoning because Patient #1 was no longer vomiting. Physician MM said that by the time she saw Patient #1 the patient was very sick, was being treated, and had received Rocephin. Physician MM said that she transferred Patient #1 because she thought the patient needed a higher level of care. Physician MM said that if she had determined that Patient #1 had sepsis (blood stream infection) she might have added another antibiotic, but Patient #1 was already receiving the first line of treatment. Physician MM said that on 7/5/19 she gave telephone orders to a nurse to admit the patient. Physician MM explained that the new computer system requires on-call physicians to enter their own orders. Physician MM confirmed that she has treated pediatric patients who have presented with sepsis in the past and that in this community the aim is to transfers those patients to a higher level of care.

During a second interview on 11/21/19 at 1:30 p.m. in the Conference Room, ED physician KK said that he thought that he had documented his calls to the on-call pediatrician. ED physician KK said the admitting physician was the on-call pediatrician MM and she would have written the admission orders. Physician KK said he considered other things during his care of Patient #1 and that he ordered a chest x-ray, additional blood work, and called the on-call pediatrician MM. Physician KK said that when patients present for a second visit within 24 hours, he usually calls the specialist on-call. ED physician KK said Patient #1 was diagnosed with flu and urinary tract infection during the first ED visit and had received a dose of Rocephin for the urinary tract infection. Physician KK explained that he questioned whether the medication had had time to take effect or was something else going on with Patient #1. Physician KK said the patient was being treated with fluids, antibiotics, oxygen, and monitoring. Physician KK stated Patient #1 was behaving the way he thought the patient should be responding during the first several hours in the ED and then Patient #1 had an increase in temperature and her heartrate increased. Physician KK said that prior to the facility's new electronic system the on-call physicians had to give their orders to one (1) of the nurses but with the new system the on-call physicians have to enter their own orders. Physician KK explained that once a patient is admitted the patient is under the care of the admitting physician but if something happens that needs treatment the nurses will alert the ED physicians and the ED physician will intervene.

During an interview on 11/21/19 at 2:40 p.m. in the Conference Room, RN PP explained that page 2 of the orders she received from the on-call pediatrician MM was continued from a template (page 1). RN PP confirmed that the orders did not contain the date and time that

Based on review of medical records, Policy and Procedure review, and staff interviews, it was determined that the facility failed to provide Medical treatment within its capacity that minimized the risk or the transfer for 1 (PT. #1) of 20 sampled medical records reviewed. Additionally, the facility failed to ensure that the risks of the transfer was documented on the facility's transfer form.

Findings were:

Review of Patient #1 ' s medical record revealed that a consent for transfer was signed by Patient #1 ' s mother on 7/5/19 at 11:27 a.m. The on -call Pediatric Hospitalist MM signed the form titled ' Physician Assessment and Certification ' on 7/5/19 and noted that Patient #1 had been stabilized such that within reasonable medical probability, no material deterioration of the patient ' s condition is likely to result from transfer. Document revealed that the receiving facility (Hospital #2) had accepted the patient and that report had been given to the accepting physician. This form revealed copies of the medical record was sent to the receiving facility and that Patient #1 was to be transported via EMS (Emergency Medical Services). This form revealed the benefit of the transfer was for a "higher level of care" there were no risks of the transfer documented.

Further review revealed in part, --7/5/19 10:51 a.m.- Physician MM notified RN HH that Patient #1 would be transferred to another facility and gave an order to administer Rocephin via IV and to increase rate of IV fluids.
--7/5/19 11:20 a.m.- RN HH gave report to the receiving facility ' s RN.
--7/5/19 11:27 a.m.- Emergency Medical Services (EMS) arrived at facility to transport Patient #1 to the receiving facility.
--7/5/19 11:35 a.m.-Physician MM ordered-Give Motrin by mouth.
--7/5/19 11:44 a.m.- RN HH documented that Patient #1 was clammy and had a respiratory rate of 54 breaths per minute and heart rate of 187 beats per minute. RN HH also noted that Patient #1 was receiving IV fluids and had been unable to urinate and that Patient #1's hands and feet were blue with blanching. RN HH noted that Physician MM assessed Patient #1.
--7/5/19 11:48 a.m.- Patient #1 ' s temperature was 103.1 degrees, heart rate was 181, respirations were 25 beats per minute, oxygen saturation was 95 %, blood pressure was 85/45. Report was given to EMS personnel and patient left the ED via stretcher enroute to an acute care hospital (Hospital C).


Review of facility policy entitled "EMTALA: (Transfer Policy and Medical Screening Exam)", policy number 4412266, last approved 1/2018, revealed the purpose was to establish clinical guidelines for MSE, stabilization, and safe appropriate transfer of patients to other facilities in compliance with EMTALA. The section of the policy titled, --TRANSFER:
--APPROPRIATE TRANSFER: A transfer to another medical facility will be appropriate only in those cases in which:
The transferring hospital: A. Will provide medical treatment within its capacity that minimizes the risks to the individual's health . . . If the physician determines, through the hospital policy, that any patient should be transferred to another facility for further care, COBRA standards must be followed. The COBRA form (Patient Transfer to Another Facility) must be completed by the nurse and physician. The physician must sign the COBRA form certifying that based upon the information available at the time of transfer; the medical benefits reasonably expected from the treatment at another facility outweigh the risks to the individual. The facility failed to ensure that their policy was followed as evidenced by: a.) Failing to ensure the On-Call Pediatric Hospitalist came to the ED when initially called by the ED Physician to provide further evaluation and treatment to minimize the risks to patient #1's health; and b.) failing to complete the EMTALA transfer form. As the transfer form lacked documentation of the risks of being transferred for patient #1.


During an interview on 11/20/19 at 2:00 p.m. in the Conference Room, ED physician LL confirmed that she is the ED Medical Director. ED physician LL confirmed that that her shift on 7/5/19 started at 7:00 a.m. She explained that when her shift began Patient #1 had already been admitted but was being held in the ED until a bed on the MS 2 South Unit was available. .ED physician LL said the on-call pediatrician MM facilitated the transfer to the receiving facility. ED physician LL confirmed that the facility does not have a pediatric unit or pediatric intensive care unit. ED physician LL said pediatric patients can be admitted to the facility's intensive care unit. ED physician LL said the decision to admit to the intensive care unit would be at the discretion of the admitting physician. ED physician LL said that she has reviewed Patient #1's medical records for both visits on 7/4/19 and that the care was appropriate for the ED, she went on to explain that Patient #1 was admitted because the patient wasn't deemed well enough to go home.

During an interview on 11/20/19 at 3:30 p.m. in the Conference Room, Pediatrician MM said that when she saw Patient #1 it was for an initial assessment around midmorning and that Patient #1 still had a fever and an elevated heartrate. Pediatrician MM said at that time she felt Patient #1 needed or might need a higher level of care. Pediatrician MM said she called the receiving hospital (hospital #2) because Patient #1 had officially been admitted. Pediatrician MM said that she thought at the time she admitted Patient #1 that the facility would be able to provide the necessary care. Pediatrician MM said that Patient #1's condition changed and that she wrote orders for Patient #1 to be transferred to the receiving hospital (Hospital#B). Pediatrician MM said she called and spoke with the accepting physician and she believes Patient #1 was to be admitted to a stepdown unit.


During a second interview on 11/21/19 at 12:55 p.m. in the Conference Room, pediatrician MM explained that on 7/5/19 her plan was to turn Patient #1 over to the patient's primary care pediatrician around 7:00 a.m. or 7:30 a.m. Physician MM explained that she thought her on-call coverage for Patient #1's was going to end at 7:00 a.m. Physician MM said she sent the primary care physician a text message to inform him that she was turning Patient #1 over to him at 7:00 a.m. Physician MM said that she did not talk to the primary care physician and when she didn't hear back from him, she checked and found out that the patient's primary care pediatrician's office was closed, and he was out-of-town. Physician MM said she usually is informed if Patient #1's primary care pediatrician's office is closed or if he is going out-of-town. Physician MM said that usually her office and Patient #1's primary care pediatrician's office are closed at the same time. When questioned as to whether she had considered any other diagnoses, Physician MM said that she did not think it was food poisoning because Patient #1 was no longer vomiting. Physician MM said that by the time she saw Patient #1 the patient was very sick, was being treated, and had received Rocephin. Physician MM said that she transferred Patient #1 because she thought the patient needed a higher level of care. Physician MM said that if she had determined that Patient #1 had sepsis (blood stream infection) she might have added another antibiotic, but Patient #1 was already receiving the first line of treatment. Physician MM said that on 7/5/19 she gave telephone orders to a nurse to admit the patient. Physician MM explained that the new computer system requires on-call physicians to enter their own orders. Physician MM confirmed that she has treated pediatric patients who have presented with sepsis in the past and that in this community the aim is to transfers those patients to a higher level of care.