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Based on hospital policy and procedure reviews and closed medical record reviews the hospital's DED staff failed to comply with 42 CFR 489.24 by failing to ensure an appropriate Medical Screening Examination (MSE) was provided by Qualified Medical Personnel (QMP); and to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 1 of 20 patients (#18) who presented to the hospital's DED with an emergency medical condition (EMC) and was discharged.

The findings include:

1. ~ cross refer to 489.24(r) and 489.24(c) Medical Screening Exam, Tag A2406.

2. ~ cross refer to 489.24(d)(1-3) Stabilizing Treatment, Tag A2407.

Based on hospital policy and procedure reviews and closed medical record reviews the hospital's DED staff failed to provide an appropriate Medical Screening Examination (MSE) by Qualified Medical Personnel (QMP) within the capabilities of the hospital for 1 of 20 patients (#18) who presented to the hospital's DED with an emergent medical condition (EMC) and was discharged.

The findings include:

Review of current hospital policy "Emergency Department Procedure In Receiving and Treating Ill or Injured Individuals" Reference # 2.001, Reviewed/Revised 08/2014, revealed "Purpose: The purpose of this policy is to establish guidelines for compliance with the Emergency Medical Treatment and Labor Act....and its implementing regulations and interpretive guidelines....in regard to screening and stabilization of patients with emergency medical conditions. Policy: Any individual who 'comes to the Emergency Department' shall be provided an appropriate medical screening examination, within the capacity of the Hospital, to determine whether or not an 'emergency medical condition' exists. If such a condition does exist, the Hospital shall provide necessary stabilizing treatment and/or an appropriate transfer, if indicated. Definitions: ...'Emergency medical condition' means either: (1) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in (i) placing the health of the individual....in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part... Procedures: Guidelines: EMTALA requires that when an individual comes to the Hospital with a suspected emergency medical condition, the Hospital must provide a medical screening examination that is reasonably calculated to identify the presence of an emergency medical condition. If an emergency medical condition is identified, the Hospital must provide stabilizing treatment within its capabilities, including admission for inpatient care where appropriate. If the Hospital is unable to fully stabilize the patient, it must arrange for an appropriate transfer to a facility with the necessary capabilities. ...Initial Assessment and Medical Screening Examination ...A Qualified Medical Professional (QMP) is a licensed physician with Emergency Department clinical privileges who is responsible for the medical screening examination. The medical screening examination may also be conducted by an Emergency Department Physician Assistant or Nurse Practitioner acting within his/her scope of practice. The examination must be reasonably calculated to determine whether an emergency medical condition exits. The medical screening examination must be conducted utilizing not only all services within the capability of the Hospital's Emergency Department, but also the ancillary services that are routinely available to the Emergency Department. In other words, all appropriate Hospital resources must be used to pursue an accurate diagnosis of the patient's condition. ...Treatment and Stabilization: ...Stabilizing Treatment. A patient whose screening has identified an emergency medical condition will receive medical care within the Hospital's capacity in order to stabilize the emergency medical condition. If a patient requires transfer, the Hospital will stabilize the patient to the best of its ability prior to such transfer, which will be carried out in accordance with Hospital Policy. ...Discharge. Disposition of the patient is the responsibility of the physician. A patient shall not be discharged with an unstabilized emergency medical condition. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care as part of the discharge instructions. The emergency medical condition that caused the individual to present to the Emergency Department must be resolved, but the underlying medical condition may persist. ..."

Hospital A, closed DED record review on 08/13/2014 for Patient #18 revealed an 8 year old female who presented ambulatory via private transportation to the DED on 04/21/2014 at 1153. Review revealed the patient was triaged by a Registered Nurse (RN #1) at 1208 (15 minutes after presentation). Review of triage nurse documentation at 1208 revealed "Chief Complaint: fever, general weakness for 1 week, brother passed away of mitocondreal [sic] disorder, currently on abx (antibiotics)." Review revealed "Pain Present: No actual or suspected pain." Review revealed vital signs (VS) were assessed as: temperature (T) 97.9 degrees Fahrenheit (F); heart rate (HR) 99; blood pressure (BP) 87/59; respiratory rate (RR) 22; oxygen saturation (O2 Sat) 98% on room air (RA). Review revealed weight 19.2 kilograms (42 pounds 5 ounces). Review revealed the patient was assigned an Acuity Level 4 - Less Urgent. Review of nursing documentation revealed at 1229: Patient rounds - quite, resting, to room 20 (36 minutes after presentation), assessment complete. Review of ED Pediatric Assessment documentation by RN #2 at 1230 revealed EENT (eyes, ears, nose throat) - Ear Symptoms: Ear, right; earache. Mouth and Throat Symptoms: Sore throat. Cardiovascular - Heart Rhythm: Regular; Nail Bed Color: Pink; Capillary Refill: Less than 2 seconds. Pulses: Left Radial Pulse 2+ Normal; Right Radial Pulse 2+ Normal; Left Dorsalis Pedis Pulse 2+ Normal; Right Dorsalis Pedis Pulse 2+ Normal. Respiratory - Respirations: Unlabored, Quiet; Respirations Pattern Description: Regular. Breath Sounds: Clear all lobes. Gastrointestinal - GI Symptoms: Nausea, Vomiting; Frequency of Vomiting: once today; Abdomen Description: Flat, Symmetric; Abdomen Palpation: Soft, Non-Tender. Bowel Sounds: Present all quadrants. Genitourinary - Urinary Symptoms: denies symptoms. Integumentary - Skin Integrity: Intact, no abnormalities; Skin Turgor: Elastic; Mucous Membrane Color: Pale; Mucous Membrane Description: Moist. Review of a Pediatric Coma Score [a neurological score that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment] assessment revealed Eye Opening Response: Spontaneously; Best Motor Response: Obeys; Best Verbal Response: Oriented and Converses. Review revealed a total Pediatric Coma Score of 15 (3 [in a coma] -15 [normal score]). Review of nursing documentation revealed at 1311: Patient Rounds - quiet, resting, waiting to be seen. At 1324: to X-ray. At 1344: lab into draw blood. At 1417: patient rounds needs met. At 1424: Heparin lock established right antecubital, intravenous fluids (IVF) of Normal Saline 0.9%, 500 milliliter (mL) bolus administered.

Review of MSE documentation by a Physician Assistant (PA #1) at 1311 (78 minutes after presentation) revealed a history source: patient, mother and father. Review of HPI (History of Present Illness) revealed, Patient is an 8-year-old Hispanic female presenting with her mother and father for evaluation of fever and weakness. Father states the patient has had symptoms ongoing over the past week. She did see her primary care physician (PCP) at (name) pediatrics on Tuesday and was diagnosed with influenza via nasopharyngeal swab. She then went back to her PCP on Thursday and was also diagnosed with acute otitis media (ear infection). Patient is on Amoxicillin (antibiotic). She is [sic] also been given Tylenol at home for fever relief. Mother states the patient broke her fever on Saturday. She however now has become extremely weak. She states that she does not even have enough energy to talk. Patient has a rare mitochondrial disorder. Mother is concerned as the patient has had a brother that passed away due to this disorder. Patient has no other known medical conditions or allergies. She was born full-term. She is up-to-date on her immunizations. Review of ROS (Review of Systems) revealed Constitutional symptoms: Fever, weakness. Skin Symptoms: Negative except as documented in HPI. ENMT symptoms: Negative except as documented in HPI. Respiratory symptoms: Negative except as documented in HPI. Cardiovascular symptoms: Negative except as documented in HPI. Gastrointestinal symptoms: Negative except as documented in HPI. Genitourinary symptoms: Negative except as documented in HPI. Musculoskeletal symptoms: Negative except as documented in HPI. Neurologic symptoms: Negative except as documented in HPI. Hematologic/Lymphatic symptoms: Negative except as documented in HPI. Allergy/immunologic symptoms: Negative except as documented in HPI. Review of Physical Examination revealed General: Alert, no acute distress. Skin: Warm, pink, intact, moist. Head: Normocephalic, atraumatic. Neck: Supple, trachea midline, no tenderness. Eye: Extraocular movements are intact, normal conjunctiva. Ears, nose, mouth and throat: Oral mucosa moist, no pharyngeal erythema or exudate, Tympanic membrane: Right, mild, erythema. Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral perfusion. Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal. Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds. Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed. Psychiatric: Cooperative, appropriate mood and affect. Review of Medical Decision Making revealed Differential Diagnosis: Fever, viral syndrome, pneumonia, bronchitis, otitis media, upper respiratory infection, sinusitis, urinary tract infection, pyelonephritis, pharyngitis, sepsis, bacteremia, influenza, meningitis. Rationale: Patient is 8-year-old female presenting for evaluation of a weakness and a fever. Patient was diagnosed with the flu past Tuesday and acute otitis media on Thursday by primary care physician at (name) pediatrics. Patient is on Amoxicillin. She did have a fever originally last week for the fever did break and [sic] (on) Saturday. Since then the patient has not had a fever. Mother and father states the patient has had generalized weakness over the past week. There concerned as the patient has a history of a mitochondrial disorder. Patient has no other known medical conditions. They are not sure of the name of the mitochondrial disorder. Patient has had no abdominal pain, nausea, vomiting. No throat pain, She denies any pain on my examination. On my exam, right TM appears a mildly erythematous. No perforation. No mastoid tenderness. Left TM is clear and intact. Lung sounds are clear. Renton [sic] her [sic] and rhythm are noted. Neck is soft and supple. No meningeal signs. No skin rashes. Abdomen is soft nontender. Patient did have a CBC (complete blood count), CMP (comprehensive metabolic panel), urine (UA), chest x-ray (CXR) but, No evidence of UTI (urinary tract infection). No evidence of pneumonia. Blood work within normal limits. She is treated in the ED with 500 mL of IV saline. At this time, I do believe the patient is safe for discharge outpatient follow up tomorrow. Advised to continue complete course of Amoxicillin. Advil. As suspicion for meningitis. Patient has no meningeal signs or skin rashes. She is tolerating by mouth fluids well. She has actually requested for something to eat. At this time, patient is discharged. Clinical impression is weakness. Patient or parents have no further questions or concerns. Patient was evaluated in conjunction with Dr. (Physician A). Refer to his note for details on patient care. Review of Impression and Plan revealed a diagnosis of general weakness. Plan - Condition: Stable. Disposition: Discharged to home. Patient was given the following educational materials: Weakness, Fatigue, and Viral Syndrome. Follow up with primary care provider within 1 to 2 days. Complete course of Amoxicillin as the patient is already on. Follow up with primary care physician tomorrow for reevaluation. Alternate Tylenol and Motrin as needed for pain or fever relief. Hydrate with plenty of fluids. Return to ER for any worsening of symptoms. Counseled: Patient, Family, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions.

Review of MSE documentation by Physician A at 1352 revealed Chief Complaint: Generalized weakness. History of Present Illness: This is an 8-year-old female with some kind of mitochondrial disorder. Mom and dad cannot describe at all what this is or what it entails. Last week she had the flu and otitis media. Was on Amoxicillin. Has never really recovered in terms of just generalized global weakness. She has had no further fever. No cough. No congestion. No runny nose. No ear pain. No vomiting. No diarrhea. No abdominal pain. Just states that ever since she has had this she has just felt weak and tired all over. No other medical history. Review of Physical Examination revealed Vital Signs: Afebrile. General: Well-appearing, nontoxic female, well hydrated. Head: Normocephalic, atraumatic. Eyes: Pupils equal and reactive to light and accommodation. Extraocular muscles are intact. Neck: Supple. Trachea midline. No cervical adenopathy. No meningismus. ENT Exam: She still has a slight otitis media on the right but she has no ear pain. Left TM is normal. Oropharynx is clear. Pulmonary: Lungs are clear to auscultation X2 bilaterally. Cardiovascular Exam: Heart regular rate and rhythm. S1, S2 noted. No murmurs, clicks, or rubs. Abdominal Exam: Active bowel sounds. Abdomen is soft, nontender, nondistended with no rebound, rigidity, or guarding. Skin: Warm and dry. No rashes. Neurologic Exam: Alert and oriented x 4 (person, place, time, situation) with clear speech. Cranial nerves 2 through 12 intact. Motor strength is 5/5 (normal) in the upper and lower extremities. Sensation intact to light touch. Normal finger-to-nose and heel-to-shin. Medical Decision Making: Chest x-ray is negative. We will check labs, urine. Give her IV fluids. Suspect postviral syndrome. Low suspicion for meningitis. No sign of otitis media.

Review revealed the following physician's orders were completed CBC, CMP, UA, CXR and a Heparin Lock, IVF 500 mL Sodium Chloride 0.9% bolus.

Review of discharge documentation revealed the patient and parents were given written and verbal discharge and follow-up instructions. Review of a discharge form revealed the hand written signature of the patient's father under "I (name) have received patient education materials/instructions and have verbalized understanding." Review revealed the patient's pain was reassessed as a 0/10 at discharge. Record review revealed the patient was discharged ambulatory at 1634.

Hospital B, closed medical record review on 08/14/2014, revealed Patient #18 presented to the DED of Hospital B on 04/21/2014 at 1911 (2 hours 37 minutes after discharge from Hospital A) via private transportation with a chief complaint of weakness. Review revealed the patient was triaged by a RN at 1922 and assigned an acuity level 2 - Emergent. Review revealed a MSE was performed by a QMP. Review revealed a chief complaint of extremity weakness. Review revealed a clinical impression of lethargy. Review revealed the patient was subsequently admitted to the Pediatric Intensive Care Unit. Review of an admissions History and Physical revealed an admission assessment of "strong family history of stroke and MELAS (Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes) who presents with increased lethargy and inability to ambulate normally. MRI (Magnetic Resonance Imaging) revealing definite stroke." The patient was discharged on 04/25/2014 (4 days later) with a diagnosis of Family history of stroke due to MELAS, Right Otitis Media, and Cerebral Infarction (CVA).

Based on policy and procedure reviews and closed medical record reviews the Dedicated Emergency Department's (DED) Qualified Medical Personnel (QMP) failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 1 of 20 patients with a emergent medical condition who was discharged (#18).

The findings include:

Review of current hospital policy "Emergency Department Procedure In Receiving and Treating Ill or Injured Individuals" Reference # 2.001, Reviewed/Revised 08/2014, revealed "Purpose: The purpose of this policy is to establish guidelines for compliance with the Emergency Medical Treatment and Labor Act....and its implementing regulations and interpretive guidelines....in regard to screening and stabilization of patients with emergency medical conditions. Policy: Any individual who 'comes to the Emergency Department' shall be provided an appropriate medical screening examination, within the capacity of the Hospital, to determine whether or not an 'emergency medical condition' exists. If such a condition does exist, the Hospital shall provide necessary stabilizing treatment and/or an appropriate transfer, if indicated. Definitions: ...'Emergency medical condition' means either: (1) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in (i) placing the health of the individual....in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part... Procedures: Guidelines: EMTALA requires that when an individual comes to the Hospital with a suspected emergency medical condition, the Hospital must provide a medical screening examination that is reasonably calculated to identify the presence of an emergency medical condition. If an emergency medical condition is identified, the Hospital must provide stabilizing treatment within its capabilities, including admission for inpatient care where appropriate. If the Hospital is unable to fully stabilize the patient, it must arrange for an appropriate transfer to a facility with the necessary capabilities. ...Initial Assessment and Medical Screening Examination ...A Qualified Medical Professional (QMP) is a licensed physician with Emergency Department clinical privileges who is responsible for the medical screening examination. The medical screening examination may also be conducted by an Emergency Department Physician Assistant or Nurse Practitioner acting within his/her scope of practice. The examination must be reasonably calculated to determine whether an emergency medical condition exits. The medical screening examination must be conducted utilizing not only all services within the capability of the Hospital's Emergency Department, but also the ancillary services that are routinely available to the Emergency Department. In other words, all appropriate Hospital resources must be used to pursue an accurate diagnosis of the patient's condition. ...Treatment and Stabilization: ...Stabilizing Treatment. A patient whose screening has identified an emergency medical condition will receive medical care within the Hospital's capacity in order to stabilize the emergency medical condition. If a patient requires transfer, the Hospital will stabilize the patient to the best of its ability prior to such transfer, which will be carried out in accordance with Hospital Policy. ...Discharge. Disposition of the patient is the responsibility of the physician. A patient shall not be discharged with an unstabilized emergency medical condition. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care as part of the discharge instructions. The emergency medical condition that caused the individual to present to the Emergency Department must be resolved, but the underlying medical condition may persist. ..."

Hospital A, closed DED record review on 08/13/2014 for Patient #18 revealed an 8 year old female who presented ambulatory via private transportation to the DED on 04/21/2014 at 1153. Review revealed the patient was triaged by a Registered Nurse (RN #1) at 1208 (15 minutes after presentation). Review of triage nurse documentation at 1208 revealed "Chief Complaint: fever, general weakness for 1 week, brother passed away of mitocondreal [sic] disorder, currently on abx (antibiotics)." Review revealed "Pain Present: No actual or suspected pain." Review revealed vital signs (VS) were assessed as: temperature (T) 97.9 degrees Fahrenheit (F); heart rate (HR) 99; blood pressure (BP) 87/59; respiratory rate (RR) 22; oxygen saturation (O2 Sat) 98% on room air (RA). Review revealed weight 19.2 kilograms (42 pounds 5 ounces). Review revealed the patient was assigned an Acuity Level 4 - Less Urgent. Review of nursing documentation revealed at 1229: Patient rounds - quite, resting, to room 20 (36 minutes after presentation), assessment complete. Review of ED Pediatric Assessment documentation by RN #2 at 1230 revealed EENT (eyes, ears, nose throat) - Ear Symptoms: Ear, right; earache. Mouth and Throat Symptoms: Sore throat. Cardiovascular - Heart Rhythm: Regular; Nail Bed Color: Pink; Capillary Refill: Less than 2 seconds. Pulses: Left Radial Pulse 2+ Normal; Right Radial Pulse 2+ Normal; Left Dorsalis Pedis Pulse 2+ Normal; Right Dorsalis Pedis Pulse 2+ Normal. Respiratory - Respirations: Unlabored, Quiet; Respirations Pattern Description: Regular. Breath Sounds: Clear all lobes. Gastrointestinal - GI Symptoms: Nausea, Vomiting; Frequency of Vomiting: once today; Abdomen Description: Flat, Symmetric; Abdomen Palpation: Soft, Non-Tender. Bowel Sounds: Present all quadrants. Genitourinary - Urinary Symptoms: denies symptoms. Integumentary - Skin Integrity: Intact, no abnormalities; Skin Turgor: Elastic; Mucous Membrane Color: Pale; Mucous Membrane Description: Moist. Review of a Pediatric Coma Score [a neurological score that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment] assessment revealed Eye Opening Response: Spontaneously; Best Motor Response: Obeys; Best Verbal Response: Oriented and Converses. Review revealed a total Pediatric Coma Score of 15 (3 [in a coma] -15 [normal score]). Review of nursing documentation revealed at 1311: Patient Rounds - quiet, resting, waiting to be seen. At 1324: to X-ray. At 1344: lab into draw blood. At 1417: patient rounds needs met. At 1424: Heparin lock established right antecubital, intravenous fluids (IVF) of Normal Saline 0.9%, 500 milliliter (mL) bolus administered.

Review of MSE documentation by a Physician Assistant (PA #1) at 1311 (78 minutes after presentation) revealed a history source: patient, mother and father. Review of HPI (History of Present Illness) revealed, Patient is an 8-year-old Hispanic female presenting with her mother and father for evaluation of fever and weakness. Father states the patient has had symptoms ongoing over the past week. She did see her primary care physician (PCP) at (name) pediatrics on Tuesday and was diagnosed with influenza via nasopharyngeal swab. She then went back to her PCP on Thursday and was also diagnosed with acute otitis media (ear infection). Patient is on Amoxicillin (antibiotic). She is [sic] also been given Tylenol at home for fever relief. Mother states the patient broke her fever on Saturday. She however now has become extremely weak. She states that she does not even have enough energy to talk. Patient has a rare mitochondrial disorder. Mother is concerned as the patient has had a brother that passed away due to this disorder. Patient has no other known medical conditions or allergies. She was born full-term. She is up-to-date on her immunizations. Review of ROS (Review of Systems) revealed Constitutional symptoms: Fever, weakness. Skin Symptoms: Negative except as documented in HPI. ENMT symptoms: Negative except as documented in HPI. Respiratory symptoms: Negative except as documented in HPI. Cardiovascular symptoms: Negative except as documented in HPI. Gastrointestinal symptoms: Negative except as documented in HPI. Genitourinary symptoms: Negative except as documented in HPI. Musculoskeletal symptoms: Negative except as documented in HPI. Neurologic symptoms: Negative except as documented in HPI. Hematologic/Lymphatic symptoms: Negative except as documented in HPI. Allergy/immunologic symptoms: Negative except as documented in HPI. Review of Physical Examination revealed General: Alert, no acute distress. Skin: Warm, pink, intact, moist. Head: Normocephalic, atraumatic. Neck: Supple, trachea midline, no tenderness. Eye: Extraocular movements are intact, normal conjunctiva. Ears, nose, mouth and throat: Oral mucosa moist, no pharyngeal erythema or exudate, Tympanic membrane: Right, mild, erythema. Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral perfusion. Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal. Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds. Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed. Psychiatric: Cooperative, appropriate mood and affect. Review of Medical Decision Making revealed Differential Diagnosis: Fever, viral syndrome, pneumonia, bronchitis, otitis media, upper respiratory infection, sinusitis, urinary tract infection, pyelonephritis, pharyngitis, sepsis, bacteremia, influenza, meningitis. Rationale: Patient is 8-year-old female presenting for evaluation of a weakness and a fever. Patient was diagnosed with the flu past Tuesday and acute otitis media on Thursday by primary care physician at (name) pediatrics. Patient is on Amoxicillin. She did have a fever originally last week for the fever did break and [sic] (on) Saturday. Since then the patient has not had a fever. Mother and father states the patient has had generalized weakness over the past week. There concerned as the patient has a history of a mitochondrial disorder. Patient has no other known medical conditions. They are not sure of the name of the mitochondrial disorder. Patient has had no abdominal pain, nausea, vomiting. No throat pain, She denies any pain on my examination. On my exam, right TM appears a mildly erythematous. No perforation. No mastoid tenderness. Left TM is clear and intact. Lung sounds are clear. Renton [sic] her [sic] and rhythm are noted. Neck is soft and supple. No meningeal signs. No skin rashes. Abdomen is soft nontender. Patient did have a CBC (complete blood count), CMP (comprehensive metabolic panel), urine (UA), chest x-ray (CXR) but, No evidence of UTI (urinary tract infection). No evidence of pneumonia. Blood work within normal limits. She is treated in the ED with 500 mL of IV saline. At this time, I do believe the patient is safe for discharge outpatient follow up tomorrow. Advised to continue complete course of Amoxicillin. Advil. As suspicion for meningitis. Patient has no meningeal signs or skin rashes. She is tolerating by mouth fluids well. She has actually requested for something to eat. At this time, patient is discharged. Clinical impression is weakness. Patient or parents have no further questions or concerns. Patient was evaluated in conjunction with Dr. (Physician A). Refer to his note for details on patient care. Review of Impression and Plan revealed a diagnosis of general weakness. Plan - Condition: Stable. Disposition: Discharged to home. Patient was given the following educational materials: Weakness, Fatigue, and Viral Syndrome. Follow up with primary care provider within 1 to 2 days. Complete course of Amoxicillin as the patient is already on. Follow up with primary care physician tomorrow for reevaluation. Alternate Tylenol and Motrin as needed for pain or fever relief. Hydrate with plenty of fluids. Return to ER for any worsening of symptoms. Counseled: Patient, Family, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions.

Review of MSE documentation by Physician A at 1352 revealed Chief Complaint: Generalized weakness. History of Present Illness: This is an 8-year-old female with some kind of mitochondrial disorder. Mom and dad cannot describe at all what this is or what it entails. Last week she had the flu and otitis media. Was on Amoxicillin. Has never really recovered in terms of just generalized global weakness. She has had no further fever. No cough. No congestion. No runny nose. No ear pain. No vomiting. No diarrhea. No abdominal pain. Just states that ever since she has had this she has just felt weak and tired all over. No other medical history. Review of Physical Examination revealed Vital Signs: Afebrile. General: Well-appearing, nontoxic female, well hydrated. Head: Normocephalic, atraumatic. Eyes: Pupils equal and reactive to light and accommodation. Extraocular muscles are intact. Neck: Supple. Trachea midline. No cervical adenopathy. No meningismus. ENT Exam: She still has a slight otitis media on the right but she has no ear pain. Left TM is normal. Oropharynx is clear. Pulmonary: Lungs are clear to auscultation X2 bilaterally. Cardiovascular Exam: Heart regular rate and rhythm. S1, S2 noted. No murmurs, clicks, or rubs. Abdominal Exam: Active bowel sounds. Abdomen is soft, nontender, nondistended with no rebound, rigidity, or guarding. Skin: Warm and dry. No rashes. Neurologic Exam: Alert and oriented x 4 (person, place, time, situation) with clear speech. Cranial nerves 2 through 12 intact. Motor strength is 5/5 (normal) in the upper and lower extremities. Sensation intact to light touch. Normal finger-to-nose and heel-to-shin. Medical Decision Making: Chest x-ray is negative. We will check labs, urine. Give her IV fluids. Suspect postviral syndrome. Low suspicion for meningitis. No sign of otitis media.

Review revealed the following physician's orders were completed CBC, CMP, UA, CXR and a Heparin Lock, IVF 500 mL Sodium Chloride 0.9% bolus.

Review of discharge documentation revealed the patient and parents were given written and verbal discharge and follow-up instructions. Review of a discharge form revealed the hand written signature of the patient's father under "I (name) have received patient education materials/instructions and have verbalized understanding." Review revealed the patient's pain was reassessed as a 0/10 at discharge. Record review revealed the patient was discharged ambulatory at 1634.

Hospital B, closed medical record review on 08/14/2014, revealed Patient #18 presented to the DED of Hospital B on 04/21/2014 at 1911 (2 hours 37 minutes after discharge from Hospital A) via private transportation with a chief complaint of weakness. Review revealed the patient was triaged by a RN at 1922 and assigned an acuity level 2 - Emergent. Review revealed a MSE was performed by a QMP. Review revealed a chief complaint of extremity weakness. Review revealed a clinical impression of lethargy. Review revealed the patient was subsequently admitted to the Pediatric Intensive Care Unit. Review of an admissions History and Physical revealed an admission assessment of "strong family history of stroke and MELAS (Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes) who presents with increased lethargy and inability to ambulate normally. MRI (Magnetic Resonance Imaging) revealing definite stroke." The patient was discharged on 04/25/2014 (4 days later) with a diagnosis of Family history of stroke due to MELAS, Right Otitis Media, and Cerebral Infarction (CVA).

NC00099231