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Based on record review and interview, the hospital failed to follow their policy and did not provide one patient (patient #1) out of 20 emergency department medical records reviewed from 2/18/11 to 7/18/11, with further examination and stabilizing treatment prior to discharge.

Findings include:

- The hospital's policy "Patient Transfers and Emergency Medical Treatment and Active Labor Act (EMTALA), ER 1-14, reviewed on 8/4/11 revealed "If an emergency medical condition is found to exist, the hospital will stabilize or transfer the patient in accordance with EMTALA."

- Patient #1, an eight year old male arrived at the hospital's emergency department accompanied by his parents from home on 5/8/11 at 8:20 PM with a fever up to 104 degrees and vomiting for the past three days. ED nurse D (registered nurse), certified in ACLS and PALS (advanced cardiac life support and pediatric advanced life support) triaged patient #1 on 5/8/11 at 8:39 PM. ED nurse D documented that patient #1 had an abnormal temperature of 104.8 degrees Fahrenheit (normal body temperature is 98.6 degrees), a pulse of 132 and that the patient complained of feeling short of breath, dizzy, vomiting, with fever and chills.
ED physician B examined the patient at 9:30 PM. Review of the medical screening examination revealed the patient complained of a fever for three days and per the family the temperature worsened with medications. The ED physician documented the patient reported shortness of breath, nausea and vomiting. The ED physician noted the patient's blood pressure was 124/67, his temperature was 104.8 degrees Fahrenheit and his pulse oximetry was 98% on room air. At 9:41 PM, ED physician B ordered a UA (urine analysis), a CBC (completed blood count), a CMP (complete metabolic panel) and at 10:20 PM a strep test. At 11:46 PM ED physician B documented in a progress note "Pt (patient) was noted to have a pulse of 140 and a temperature of 103." "I felt the pulse was excessive, even for an elevated temperature." "I ordered IVF but the nursing staff was unable to get an IV catheter placed." "After the 2nd attempt the father refused further attempts." At 11:46 PM the physician ordered Tylenol 500 milligrams to treat Patient # 1's fever. At 11:53 PM, the nurse reviewed the discharge instructions with the patient's mother and the mother signed the form. Discharge instructions specified Patient # 1 had a febrile illness and viral syndrome and fluids should be encouraged along with over the counter fever reducing medications and follow-up in 2-4 days with primary care physician. The physician signed the discharge instructions sheet at 12:04 AM (5/9/11) and noted the patient's pulse was 128 and his temperature was 103.4. At 12:14 AM patient #1 left the ED.

- The medical record did not contain evidence that the ED performed a septic work up to determine whether patient #1 had a serious bacterial infection or provided treatment to stabilize his emergency (prolonged high fever with abnormal vital signs for age.)

- Review of the Hospital Medicare Database worksheet completed by hospital staff on 7/18/11, revealed the hospital's capabilities included an intensive care unit and pediatric services.

- Administrative staff C, Registered Nurse/Chief Nursing Officer, in a document dated 8/4/11 indicated that if a nurse has made three unsuccessful attempts to start an IV another nurse should be consulted. If the two nurses decide there is no possibility of starting an IV, they would notify the doctor that a consult with an Anesthetist is needed.

- Staff D, Registered Nurse in the ED, interviewed via telephone on 7/18/11 at 2:00 PM shared he recalled patient #1 had a fever with mild dehydration. Staff D attempted to start an IV twice on patient #1 and patient #1 jumped and was told "to hold still." Staff D stated the patient's father became upset and said, "you are not going to make a pin cushion out of my son" and then refused to allow any further attempts to start the IV by Staff D.

Refer to Tag C-2407 for further details.

Based on record review and interviews, the hospital failed to provide one patient (patient #1)
out of 20 emergency department medical records reviewed from 2/18/11 to 7/18/11, with further examination and stabilizing treatment within its capabilities prior to discharge.

Findings include:

- Patient #1, an eight year old male arrived at the hospital's emergency department accompanied by his parents from home on 5/8/11 at 8:20 PM with a fever up to 104 degrees and vomiting for the past three days. ED nurse D (registered nurse), certified in ACLS and PALS (advanced cardiac life support and pediatric advanced life support) triaged patient #1 on 5/8/11 at 8:39 PM. ED nurse D documented that patient #1 had an abnormal temperature of 104.8 degrees Fahrenheit (normal body temperature is 98.6 degrees), a pulse of 132 and that the patient complained of feeling short of breath, dizzy, vomiting, with fever and chills.
ED physician B examined the patient at 9:30 PM. Review of the medical screening examination revealed the patient complained of a fever for three days and per the family the temperature worsened with medications. The ED physician documented the patient reported shortness of breath, nausea and vomiting. The ED physician noted the patient's blood pressure was 124/67, his temperature was 104.8 degrees Fahrenheit and his pulse oximetry was 98% on room air. At 9:41 PM, ED physician B ordered a UA (urine analysis), a CBC (completed blood count), a CMP (complete metabolic panel) and at 10:20 PM a strep test. At 11:46 PM ED physician B documented in a progress note "Pt (patient) was noted to have a pulse of 140 and a temperature of 103." "I felt the pulse was excessive, even for an elevated temperature." "I ordered IVF but the nursing staff was unable to get an IV catheter placed." "After the 2nd attempt the father refused further attempts." At 11:46 PM the physician ordered Tylenol 500 milligrams to treat Patient # 1's fever. At 11:53 PM, the nurse reviewed the discharge instructions with the patient's mother and the mother signed the form. Discharge instructions specified Patient # 1 had a febrile illness and viral syndrome and fluids should be encouraged along with over the counter fever reducing medications and follow-up in 2-4 days with primary care physician. The physician signed the discharge instructions sheet at 12:04 AM (5/9/11) and noted the patient's pulse was 128 and his temperature was 103.4. At 12:14 AM patient #1 left the ED.

- The medical record did not contain evidence that the ED performed a septic work up to determine whether patient #1 had a serious bacterial infection or provided treatment to stabilize his emergency (prolonged high fever with abnormal vital signs for age.)

- Review of the Hospital Medicare Database worksheet completed by hospital staff on 7/18/11, revealed the hospital's capabilities included an intensive care unit and pediatric services.

- Administrative staff C, Registered Nurse/Chief Nursing Officer, in a document dated 8/4/11 indicated that if a nurse has made three unsuccessful attempts to start an IV another nurse should be consulted. If the two nurses decide there is no possibility of starting an IV, they would notify the doctor that a consult with an Anesthetist is needed.

- Staff D, Registered Nurse in the ED, interviewed via telephone on 7/18/11 at 2:00 PM shared he recalled patient #1 had a fever with mild dehydration. Staff D attempted to start an IV twice on patient #1 and patient #1 jumped and was told "to hold still." Staff D stated the patient's father became upset and said, "you are not going to make a pin cushion out of my son" and then refused to allow any further attempts to start the IV by Staff D.

- ED physician B interviewed on 7/19/11 at 2:14 PM stated the patient presented to the ED with a fever for several days. He stated the patient had redness on his face, neck and arms but after his examination he attributed the redness to the fever. He stated the patient did not have a rash. ED physician B stated after his examination he explained to the father and family that the patient's fever was due to a virus and that the patient was dehydrated. He told them he wanted to draw lab tests and give the patient IV fluids. ED physician B stated the family verbalized understanding of the treatment. He shared the family did tell him the patient had been in the woods mushroom hunting and asked about tick disease. ED physician B stated he asked the family if they had found a tick on the patient and the family told him no. Later on, nursing staff approached him and told him that they were unable to start the IV after two attempts. They also told him the father was refusing to allow the IV. ED physician B stated he went to talk with the father. The father told him, he was upset with how many times his son had been poked and that he did not like the attitude of the staff. ED physician B stated he offered to find someone else to start the IV and that the father declined. ED physician B stated the father was adamant that no further treatment be done.
- The medical record did not contain any evidence that the patient or family refused further examination, that the ED nurse or physician contacted the anesthesia department for expert assistance in starting an IV or that the ED physician explained the risks of refusing an IV prior to discharging patient #1 with instructions to follow up with a primary care physician in 2 - 4 days.

- In an interview on 8/3/11 at 2:00 PM, patient #1's mother stated she and her husband took their son to the Atchison Hospital ED because he felt fatigued, had a high temperature, and they were concerned he may have been bitten by a tick while mushroom hunting. The mother said the ED nurse took her son's temperature and it was 103 degrees; that the ED physician came in briefly to check on her son and ordered some blood work; and that the lab person tried three times to get blood from her son's arm and finally got some blood from his finger. The mother said the nurse told the lab person her son was "highly dehydrated." The mother said the nurse tried to start an IV; made two (2) attempts one in each arm and then tried to poke the patient's wrist to get the IV started, but was unsuccessful. The mother said the nurse yelled at her son for jerking his arm and that her husband told the nurse to stop poking our son. The mother said the nurse did not offer to get someone else to start the IV. The mother said she was told her son was "highly dehydrated" but no one talked about admitting him or transferring him to another hospital. The mother said she was told her son had a viral infection and they should follow-up with their primary care physician. The mother said she took her son to the physician the next day (5/10/11), but they remained concerned so she and her husband took him to a second hospital (Hospital B) where her son was admitted to the intensive care unit (Hospital B) and was diagnosed with meningitis and a tick borne illness.

- Review of Hospital B's medical record revealed patient #1 presented to the ED on 5/12/11 at 1:41 AM exhibiting signs of shock (life threatening condition) and was admitted to the intensive care unit for further stabilizing treatment.

- According to the statutorily mandated Quality Improvement Organization review performed on 8/2/11, Atchison Hospital failed to provide patient #1 with treatment to stabilize his emergency prior to discharge from the ED on 5/9/11.