HospitalInspections.org

Based on record review and interview, the hospital failed to consistently provide appropriate medical screening exams (MSE) that involved the use of ancillary studies and procedures from 07/01/18 to 08/01/18 for a sample of one (#1) of 12 patients who presented to the hospital's emergency department with complaints of fall, traumatic injuries, abdominal pain, nausea and/or vomiting.
This failed practice resulted in a pediatric patient with an emergency medical condition, a Grade IV splenic laceration, (The American Association for the Surgery of Trauma (AAST) injury scoring scale is the most widely accepted system of classifying and categorizing traumatic injuries. Grades are categorized according to severity, with Grade I being the lowest severity and Grade V being the highest severity) being undiagnosed. And had the potential for all patients who presented to the emergency department with similar presentations to be discharged without diagnosis of an emergency medical condition.

Findings:
A review of a sample of 12 ED medical records for patients who presented with complaints of a fall, trauma injuries, abdominal pain, nausea and/or vomiting showed 8 (Patient #4, 8, 18, 19, 20, 22, 23 and 25) of 12 patients were provided stabilizing treatment following completion of an appropriate MSE by a qualified physician, that included x-rays, CT scan, laboratory studies, intravenous (IV) fluids and/or medications.

A review of hospital policy "Medical Screening Examination" (MSE), reviewed 04/18, defined MSE as the appropriate examination, within the capability of the hospital's emergency department. The document also showed the MSE and the patient's medical records "are to reflect continued monitoring according to the patient's needs and must continue until the patient is either stabilized or appropriately transferred."

A review of Patient #1's medical record showed:
On 08/13/18 patient #1 presented to the ED following a recommendation from a primary care provider.
The chief complaint was documented at 3:58 pm as "hit abdomen on steps of playground - nausea/vomited x 3".
4:11 pm Staff C triaged patient as a level three (defined by the facility as an "urgent condition stable at the time of assessment; unlikely to deteriorate in one hour").
5:07 pm Staff A documented "very mild ecchymosis around each shoulder"
5:13 pm Staff B documented "patient complains of neck pain but Mom states he did not fall on head or land on neck. Initial complaints were abdominal and chest wall pain from fall".
5:45 pm Staff B administered 464.3 mg of oral acetaminophen as ordered by Staff A.
5:46 pm Staff B documented pain as 4 (moderate pain) on Wong-Baker FACES pain assessment scale (assessment tool used as standard for assessing pediatric pain levels).
5:47 pm patient was discharged with instructions for fall prevention.

A document, "Emergency Department Protocols", effective 02/16, showed protocol for Vomiting/Abdominal Pain included, but were not limited to: insertion of a saline lock (intravenous access), obtain laboratory tests including a urinalysis and hold oral intake.

A policy, "EMTALA Requirements and Flow Chart", reviewed 04/18, showed treatment of the patient's medical condition should be provided as necessary to assure there would not likely be deterioration of the patient's medical condition.

Review of a document titled "Advances in Pediatric Abdominal Trauma: What's New in Assessment and Management", Trauma Reports, issue date 09/01/16, showed pediatric patients are at greater risk for solid organ injuries including splenic injury, secondary to the larger abdominal organs. The spleen and liver are the most frequently injured organs. In patients who are hemodynamically stable (vital signs are within normal limits), with low or moderate concern about intra-abdominal injury, the minimum set of laboratory tests should be:

hematocrit (the volume percentage of red blood cells in the blood),
aspartate aminotransferase (AST) alanine aminotransferase (ALT) (blood tests used to determine liver damage)
urinalysis
The article also showed if chest wall trauma is suspected a chest x-ray should be ordered, and the gold standard for determining intra-abdominal injuries is a CT scan and should be used based on physical exam findings, patient history, and clinical decision rules or criteria.

Review of a medical record for patient #1 dated 08/13/18 showed:
10:40 pm, showed patient presented to the ED of another medical facility for evaluation post- fall. Patient complaining of head/neck pain, had vomited 6 times since injury.
11:24 pm, the ED physician ordered diagnostic laboratory tests including: comprehensive metabolic panel, complete blood count with differential, blood typing and screening and urinalysis.
11:24 pm, the ED physician also ordered the following diagnostic radiography tests: x-ray of the cervical spine and a CT (computerized tomography) with contrast (an intravenous solution used to enhance images).

Review of a medical record for patient #1 dated 08/14/18 showed:
12:50 am, the physician documented "there is a splenic laceration measuring 4.5 cm, with hemoperitoneam ", "minimally displaced fractures of the left 7th and 8th ribs on the left"
3:10 am, the physician initiated transfer of patient to a trauma facility, the patient was subsequently transferred and admitted to another facility's pediatric intensive care unit where patient had a five day stay.

On 09/06/18 at 9:06 am, Staff C stated he/she triaged Patient #1 as a Level 3 (urgent) on the Emergency Severity Index (ESI)(the standard triage system utilized in emergency care to determine patient acuity based on physical impression and the resources he/she expected the patient would receive). He/she stated a patient with complaints of abdominal pain would probably need an x-ray, CT scan, IV fluids and possibly nausea medication.

On 09/06/18 at 10:10 am, Staff A stated there were no indications for diagnostic imaging or laboratory studies based on low suspicion for abdominal trauma and he/she was cautious regarding radiation with pediatric patients. Staff A also stated the facility did not have procedures or protocols for the treatment of blunt abdominal trauma for pediatric patients and that he/she did not rely on protocols when care was administered.