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Based on interviews, policy review, and record review, the hospital failed to comply with the regulatory requirements for EMTALA when:

1. Patient (Pt) 1, a pediatric patient with special needs (physical, medical, developmental, or cognitive conditions that require special consideration), was brought to Hospital A's emergency department (ED) on 11/30/23 at 1:09 a.m. with a chief complaint (a concise statement describing the symptom, problem, and/ or condition for seeking emergent care) of abdominal pain and possible constipation. Pt 1 was not appropriately screened and prioritized per emergency severity index (ESI- a tool used in the ED to prioritize patients based on the stability of vital signs, degree of distress, expected staff response, and time to disposition), nor provided a medical screening examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) existed. The Qualified Medical Person (QMP- a healthcare professional designated by the hospital's governing body to perform an MSE) on 11/30/23 (Family Nurse Practitioner [FNP] 1) did not conduct a physical examination and failed to identify Pt 1's emergency medical condition (EMC) according to laboratory results completed on 11/30/23 at 2:24 a.m. that indicated Pt 1 had a high white blood cell count (WBC- 24,000 K/mm3) and blood glucose level (BG- 275 mg/dl). Pt 1 was discharged home with family on 11/30/23 at 04:41a.m. The patient returned to the ED at 08:39 a.m. on 11/30/23 via emergency medical services in cardiac arrest. Several rounds of advanced cardiopulmonary life support were completed but were unsuccessful and Pt 1 was pronounced on 11/30/23 at 09:09 a.m. (Refer to 2406)


Because of the serious actual harm (death) that occurred with the care of Patient 1 not receiving an appropriate and timely Medical Screening Exam (MSE) to determine an emergency medical condition (EMC) and the serious potential harm to all patients related to not receiving an appropriate and timely MSE, an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) situation was called for CFR 489.24 - A2406 on 12/14/23 at 3:35 p.m. with the President Central California Network, Chief Medical Officer, Patient Care Executive, Interim Patient Care Executive, Director Regulatory Compliance, Executive Operations, Director of Quality and Risk, Incoming Patient Care Executive, System Director Accreditation and Licensing, and Emergency Department Director on 12/14/23 at 3:35 p.m. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 12/18/23. The IJ Plan of Removal included but was not limited to the following: 1) RNs appropriately triage, prioritize and establish an accurate ESI and to obtain vital signs upon admission, 2) RNs appropriately determine the next steps following an accurate ESI, 3) The QMP always conducts an appropriate MSE that includes a physical assessment, differential diagnoses and determine stabilizing measures when an EMC is identified, 4) Follow up on all critical and abnormal laboratory results 5) RNs and all ED staff appropriately address ED and EMTALA requirements for special need children. On 12/18/23 the components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 12/18/23 at 4:37 p.m. with the facility Chief Medical Officer, Director of Quality and Risk, Director of Regulatory Compliance, and Regulatory Specialist.

The cumulative effect of these systemic failures resulted in the inability of the hospital to provide care in a safe and quality manner in the Emergency Department and was not in compliance with the statutory requirement of EMTALA.

Based on observation, interview, and record review the hospital failed to provide an appropriate medical screening examination (MSE- an assessment performed by Qualified Medical Personnel [QMP] for the purpose of determining whether an emergency medical condition [EMC] exists) within the capability of the hospital's emergency department (ED) for one of 23 patients (Patient 1) when:

1. Patient 1 was admitted to the Emergency Department (ED) on 11/30/23 at 1:09 a.m. for abdominal pain and possible constipation. No physical assessment was conducted and vital signs (blood pressure [BP], heart rate [HR], respirations [R], temperature [T], and oxygen saturation [O2sats]) were incomplete. The hospital did not appropriately assess, prioritize, and provide medical and/or emotional support to Pt 1, a pediatric patient with special needs (physical, medical, developmental, or cognitive conditions that require special consideration) and nurses permitted the family to take Pt 1 to the car to wait. The Qualified Medical Person (QMP- a healthcare professional designated by the hospital's governing body to perform an MSE) on 11/30/23 (Family Nurse Practitioner [FNP] 1) failed to identify Pt 1's emergency medical condition (EMC) according to laboratory results completed on 11/30/23 at 2:28 a.m. that indicated Pt 1 had a high white blood cell count (WBC- 24,000 K/mm3) and blood glucose level (BG- 275 mg/dl). The hospital had knowledge of grievances filed against FNP 1 and continued to permit FNP 1 to work in the ED triage area. Pt 1 was discharged home with family on 11/30/23 at 4:41a.m. The patient returned to the ED at 8:39 a.m. on 11/30/23 via emergency medical services in cardiac arrest (no heart function). Several rounds of advanced cardiopulmonary life support (ACLS) were completed but were unsuccessful and Pt 1 was pronounced dead on 11/30/23 at 9:09 a.m.


Because of the serious actual harm (death) that occurred with the care of Patient 1 not receiving an appropriate and timely Medical Screening Exam (MSE) to determine an emergency medical condition (EMC) and the serious potential harm to all patients related to not receiving an appropriate and timely MSE, an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) situation was called for CFR 489.24 - A2406 on 12/14/23 at 3:35 p.m. with the President Central California Network, Chief Medical Officer, Patient Care Executive, Interim Patient Care Executive, Director Regulatory Compliance, Executive Operations, Director of Quality and Risk, Incoming Patient Care Executive, System Director Accreditation and Licensing, and Emergency Department Director on 12/14/23 at 3:35 p.m. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 12/18/23. The IJ Plan of Removal included but was not limited to the following: 1) RNs appropriately triage, prioritize and establish an accurate ESI and to obtain vital signs upon admission, 2) RNs appropriately determine the next steps following an accurate ESI, 3) The QMP always conducts an appropriate MSE that includes a physical assessment, differential diagnoses and determine stabilizing measures when an EMC is identified, 4) Follow up on all critical and abnormal laboratory results 5) RNs and all ED staff appropriately address ED and EMTALA requirements for special need children. On 12/18/23 the components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 12/18/23 at 4:37 p.m. with the facility Chief Medical Officer, Director of Quality and Risk, Director of Regulatory Compliance, and Regulatory Specialist.


Findings:

1. During concurrent observation and interview, on 12/12/23, at 10 a.m. in Hospital A's ED main lobby waiting room (WR), with the Emergency Department Director (EDD) and Medical Director Emergency Department (MED), an escorted tour of the ED was conducted. The WR had a large desk with two staff persons registering patients. The EDD stated the registration desk was staffed with a receptionist and a "quick look" nurse whose primary function was to monitor the WR and take vital signs of patients. The WR had three triage (the initial assessment of patients to determine the urgency of their need for treatment, and the treatment required) rooms. The EDD stated triage was monitored and operated by registered nurses (RN) and qualified medical providers (QMPs also referred to as Advanced Practice Providers [APP] e.g., physician assistant, family nurse practitioner, etc.). The EDD stated the process was for patients who "walked in" the ED to stop at the reception desk to provide the reason for ED visit (chief complaint), have vital signs checked by the "quick look" nurse, and wait in WR until triaged. During triage, patients were evaluated by a RN and QMP, and provided a history of their medical condition, allergies, and prescribed medications. The EDD stated the RN assigned an emergency severity index (ESI- a tool used to categorize patients from level one, the most critically ill, to level five, the least critically ill and resource intensive) score based on the patient's presentation to help to prioritize care. The EDD stated patients with ESI score one, two, or three were directed to an ED room and those who scored four or five returned to WR. The EDD stated all ED patients' vital signs were checked every two hours or more frequently based on the needs of patients and underlying medical conditions. The MED stated the MSE was performed concurrently during triage and completed after the QMP completed the initial face to face evaluation.

During a review of Pt 1's "Registration Record (RR- form that contains essential demographic, financial, and medical information)", dated 11/30/23, the "RR" indicated Pt 1 was an eight-year-old male who arrived in the hospital emergency department on 11/30/23 at 1:09 a.m. Initial Diagnosis was constipation, abdominal pain. (First visit to ED on 11/30/23)

During a review of Pt 1's "Emergency Department Reports (EDR)" dated 11/30/23, the "EDR" indicated Pt 1 was triaged on 11/30/23 at 1:23 a.m. The FNP initiated the face-to-face medical screening exam (performed by a qualified medical professional to determine whether a patient has an emergency medical condition [EMC]) on 11/30/23 at 1:15 a.m. and "completed" at 1:19 a.m. the same day. An ultrasound (an imaging test that uses sound waves to make pictures of organs, tissues, and other structures inside your body) of the appendix (a small pouch attached to the large intestine) was performed on 11/30/23 at 2:38 a.m. and laboratory studies at 2:24 a.m. Pt 1 was discharged from the ED on 11/30/23 at 4:48 a.m. to "Home or Self Care."

During a review of Pt 1's "ED Physician Notes *Final Report*," dated 11/30/23 at 1:28 a.m., the "ED Physician Notes" indicated, " ... Pt is a 8 yo male who was brought in by mom c/o [complained of] abd [abdominal] pain x [times] today Mom states he is having associated viral illness (diagnosed earlier by pmd [primary medical doctor] but was not having abdominal pain at that time) Mom states pt has hx [history] constipation and gave him benefiber, apple juice and stool softener Mom states they did not give him anything for pain PMH [past medical history] autism [a spectrum disorder with a broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication]... Triage Vital Signs ... 01:22 [a.m.] T [temperature]: 97.8 F [Fahrenheit] HR [heart rate]: 82 RR [respiratory rate] 20 SPO2 [oxygen reading]: 96%... General ... autistic with verbal outbursts ... Cardiovascular [related to heart and blood]: Regular rate and rhythm, Normal peripheral perfusion Respiratory [movement of air through lungs]: Lungs are clear to auscultation [listening for sounds], respirations are non-labored ... Gastrointestinal [stomach and intestines]: Soft, nontender, Normal bowel sounds ... Lab Results Date 11/30/23 02:24 a.m.

... Neutrophil [part of the immune system (defends against infection) Absolute [total] 15.3 K/mm3 [thousand cells per cubic meter] (HIGH)

... Lymphocyte [part of the immune system] Absolute 6.0 K/mm3 (HIGH)

... Monocyte [part of immune system] Absolute 1.9 K/ mm3 (HIGH)

... WBC [white blood cell, protects against infection) 24.00 K/ mm3 (HIGH)

... RBC (red blood cell, component of blood that carries oxygen) 5.16 M / mm3 [millions per cubic millimeter] (HIGH) ...

... HGB [hemoglobin, oxygen carrying protein in RBC] 13.8 gm/ dl [grams per deciliter] (HIGH)

... HCT [hematocrit, percent of RBC in blood] 42.0% (HIGH)

... Glucose [sugar], Random 275 mg/ dl [milligrams per deciliter- unit of measure] (HIGH)

... 11/30/23 02:40 a.m ... UA [urinalysis, examination of urine] - Specific Gravity [chemical particles in the urine] 1.09 (HIGH)

... UA - Glucose >= 500 mg/ dl (ABNORMAL)

... UA - WBC 7/HPF [high power field] (HIGH)

... UA- Crystals CA oxalate [calcium] small (ABNORMAL)

... US [ultrasound- imaging test that uses sound waves to make pictures of structures within the body] Appendix [muscular structure attached to the large intestine] November 30, 2023 02:28 [a.m.] ... Impression: Nonvisualization of the appendix with no evidence of free fluid or rebound tenderness during scanning ... Medical Decision Making Problems addressed: Patient is 8 Years old Male with no significant medical history including hypertension, diabetes mellitus, recent antibiotic use, or immunodeficiency ... This patient did not have any chronic illnesses which impacted care ... Patient remained medically stable throughout their ED stay and review of the physical examination/ vital signs have demonstrated that there is no acute medical nor surgical emergency that requires admission or transfer to a higher level of care and that this patient is stable and appropriate for outpatient management ... No escalation of hospital level care at this point in time ... No discussions of [with] other providers took place ... No discussions or tests were done with any external or internal providers ... Notes: Diagnosis and treatment consistent with Nurse Practitioner standardized procedures ... Condition ... Stable ..." No discharge vital signs were documented.

During a review of Pt 1's second "RR", dated 11/30/23, the "RR" indicated Pt 1 was brought back to the ED by emergency medical services (EMS- ambulance) on 11/30/23 at 8:38 a.m., 230 minutes after being discharged from the ED at 4:48 a.m. on 11/30/23.

During review of Pt 1's ambulance run sheet (medical record for ambulance services) document "Ambulance Report," dated 11/30/23, the document indicated, " ... AOS to home of 8/o [year old] male in cardiac arrest [sudden, unexpected loss of heart function, breathing, and consciousness]. Patient was found lying supine [horizontal with face up] with compressions [the act of applying pressure to someone's chest to help blood flow through the heart in an emergency] being performed by fire on scene. Per family member on scene, pt was taken into the hospital last night for severe abdominal pain but was discharged with a virus. Pt now in cardiac arrest first rhythm reading PEA [pulseless electrical activity]. Pt placed on cardiac monitor and moved to backboard for stat [immediate] transport to hospital... During transport, pt is cold to touch now in asystole [no heartbeat], remains apneic [not breathing], no improvement. Unable to establish vascular [in a vein] access x 2/ Unable to establish IO [intraosseous- in a bone] access. ETA [estimated time of arrival] call in is made, continuous compressions/ ventilations [circulation of air] are done en route, no change in cardiac rhythm. Pt is GCS 3 [Glasgow coma scale- tool used to measure level of consciousness, score 3 = deep coma or death] remains in cardiac arrest as patient is moved over to hospital bed for continuity of care ... First CPR [cardiopulmonary resuscitation] 08:16:23 [a.m.] ...Primary Impression: Cardiac arrest- Non- traumatic ...08:26:32 [a.m.] BP [blood pressure] Exam Finding Not Present ... Pulse [HR] 0 ... Rhythm Absent ... Resp [respirations] Exam Finding Not Present ... Effort Apneic ... 08:26:42 [a.m.] Oxygen ... Bag valve mask (BVM) [handheld device to mechanically ventilate a patient not breathing] ... 1.5 Liters Per Minute (LPM [gas]) ... 08:32:45 [a.m.] ... No eye movement when assessed ... No Motor Response ... No verbal/ vocal response ... Transfer of Care: 11/30/23 08:37:45 [a.m.] ..."

During a review of Pt 1's "ED Triage and Initial Assessment", dated 11/30/23, the "ED Triage and Initial Assessment" indicated, " ... Reason for visit history: Code in progress on EMS arrival. Abd pain x 2 days per EMS. Possible down time of 8-10 minutes pre ems arrival, per family report/ ems report,. No family at bedside on EMS arrival. Dry dark brown vomitus like residue on face ... Triage ... Temperature (F): 94.3 DegF ... (
During a review of Pt 1's "Clinical Note ED", dated 11/30/23, the "Clinical Note ED" indicated, " ... Pediatric pt BIBA [brought in by ambulance] from home CC [chief complaint] Cardiac Arrest. Per report family checked on pt and he had vomit on self and was unresponsive. 911 was called, Fire arrived first and initiated compressions approx 10 minutes s/p [status post] found down. Per EMS patient had "dark vomit" was "cold to touch" and showed PEA on the monitor, they did a "load and go" and the code was worked enroute, Fire had previously placed OPA [oropharyngeal tube- used to maintain airway open] and pt was being compressed and ventilated the whole trip .... Pt arrived in ED at 0838 [8:38 a.m.] ... Upon arrival patient was moved to our gurney, compressions immediately continued and pt was bagged. Pt placed on pads and asystole showed on the monitor. EMS IO [intraosseous] removed IO placed here by another RN to L [left] shin [front of leg between knee and foot], IV [intravenous- in a vein] established by this RN to L AC [antecubital- bend of elbow] (22 g [gauge- size]) @ 0842 [8:42 a.m.] and first round of EPI [epinephrine- medicine used to restore heart rhythm] given through this line, see code sheet. LR [Lactated Ringer's solution- fluid used to treat dehydration and restore fluid balance in the body] was connected to IO and slowly dripped in, additional IV place to R [right] AC ... Fluids connected to this line and pressure bagged in ... no labs were obtained during the code. Cardiac activity was checked with each pulse by palpation, doppler, monitor and US throughout the code, and compressions were promptly resumed. TOD [time of death] called at 0909 [9:09 a.m.] after confirmation of no cardiac activity shown on US ... Coroner spoke to MD [medical doctor] on oficers [Officer's] phone and asked for CT scans [computed tomography- diagnostic imaging procedure], scans ordered and patient taken to CT ..."

During a review of Pt 1's "Cardiac Respiratory Code (CRC) Record", dated 11/30/23, the "CRC Record" indicated, " ... Time initiated: 0838 [8:38 a.m.] Arrest Type: Cardiac [heart] ... AIRWAY/ VENTILATION ... Type: ETT [endotracheal tube- placed through the mouth to the windpipe to help assist breathing] ... Intubation: Time 0845 [8:45 a.m.] Size 5 ... BLOOD GLUCOSE LEVELS 0839 [8:39 a.m.] ... Value: 443 ..." Epinephrine 0.33 mg [milligrams- unit of measure] was administered to Pt 1 at 8:42 a.m., 8:44 a.m., 8:47 a.m., 8:50 a.m., 8:53 a.m., 8:56 a.m., 8:59 a.m., 9:02 a.m., 9:05 a.m., and 9:08 a.m. Sodium bicarbonate (medicine to counteract acid build up in the body) 33 mEq (milliequivalents- unit of measure) was administered to Pt 1 at 8:46 a.m., 8:51 a.m., and 8:57 a.m. and Calcium Chloride (medicine used during a code to increase heart contractions and electrical activity) 600 mg at 8:55 a.m. Advanced cardiac life support measures in the ED continued for 31 minutes, return of spontaneous circulation (ROSC- restart of a sustained heart rhythm after cardiac arrest) was not achieved. Pt 1 was pronounced dead at 9:09 a.m.

During a concurrent interview and record review, on 12/13/23 at 9:30 a.m. with the Emergency Department Manager (EDM) and Emergency Room Director (EDD), Pt 1's "Electronic Medical Record (EMR- electronic version of a patient's medical history)" dated 11/30/23, the EDM validated the sequence of events during Pt 1's visits to the ED on 11/30/23. Upon further review, the EDM stated Pt 1, a pediatric patient accompanied by his parents and with a history of autism, was admitted to the ED on 11/30/23 for abdominal pain and constipation and triaged by RN 1 at 1:22 a.m. The EDM stated there was no blood pressure or gastrointestinal assessment (relating to stomach and intestines) documented in Pt 1's EMR and Pt 1's home medication list was incomplete. The EDM stated the pain level documented for Pt 1 was 10/10 on the "Numeric Pain Scale" (a simple pain scale that grades pain levels from 0 [no pain], 1,2, and 3 [mild], 4,5, and 6 [moderate], 7,8, and 9 [severe] to 10 [worst pain possible]) to his abdomen for which Pt 1 was administered Motrin 250 mg once at 2:18 a.m. and no pain reassessment was documented. The EDM stated Pt 1 was assigned an ESI score 4, therefore directed to wait further workup in the WR. The EDM stated laboratory studies and ultrasound were ordered and reviewed by FNP 1. Notable were Pt 1's elevated WBCs (24,000 K/ mm3) and blood glucose levels (275 mg/ dl) indicated in the laboratory results. The EDM stated Pt 1 was discharged home from the ED on 11/30/23 at 4:48 a.m. There was no documented evidence that Pt 1's vital signs were documented throughout the ED visit nor were vital signs taken prior to Pt 1's discharge. The EDM stated RN 1 did not follow hospital policy and procedure for abnormal laboratory values and patient follow up. The EDM stated the expectation was that patients evaluated in the ED had a complete set of vital signs (BP, HR, R, T, and oxygen saturation [O2sats]) 30 minutes prior to discharge. The EDM stated a point-of-care test (POCT- a portable device is used to test blood glucose at bedside) for blood glucose should have been done prior to Pt 1 leaving the ED to ensure Pt 1 was stable. The EDM stated Pt 1 did not have a history of diabetes and elevated glucose in blood and urine was abnormal. The EDD stated she did not agree with the ESI score assigned to Pt 1. The EDD stated Pt 1 should have been prioritized ESI score 3 based on age, behavior, and pain level. The EDD stated Pt 1's presentation and laboratory results should have prompted RN 1 to reassess Pt 1 and ask about the appropriateness of Pt 1's discharge from the ED.

During an interview on 12/13/23 at 4:44 p.m., with RN 1 and the EDD, RN 1 confirmed she worked the night shift on 11/29/23 (7 p.m. to 7 a.m. on 11/30/23) and was assigned to triage patients. RN 1 stated the triage area was usually staffed with two to three nurses in the "green zone" (fast track area), however the ED was short staffed that night and the "green zone" was closed; patients were directed to wait in WR until triaged. RN 1 stated the WR was staffed with an ED technician (EDT1) who assisted with vital signs and reported changes in the patients' conditions. RN 1 stated a "medical surg" (medical surgical) nurse (RN 2) was also "floated" to the ED to assist her with the patients. RN 1 stated Pt 1 arrived at the ED on 11/30/23 "around 1:00 a.m." RN 1 stated she did not immediately triage Pt 1 upon his arrival because there were four patients that still needed to be triaged. RN 1 stated Pt 1 yelled "so loud" in pain, which prompted her to leave the triage area and check the WR. RN 1 stated she saw that Pt 1 was a young boy "guarding" (involuntary reaction to protect an area of pain) the "middle area" of his stomach. RN 1 stated she triaged Pt 1 at 1:22 a.m. and was informed by Pt 1's mother that Pt 1 had a history of autism and chronic constipation. RN 1 stated Pt 1's vital signs were "normal" (SpO2, HR, T, and R), however she could not obtain Pt 1's blood pressure "because the cuff kept squeezing his arm and reading 200." RN 1 stated the ED provider (FNP 1) was stationed right next to her in the triage area. RN 1 stated FNP 1 asked Pt 1's mother for the reason for the ED visit and informed Pt 1's mother that she would order laboratory studies and an ultrasound, then walked away from the triage area. RN 1 stated FNP 1 did not conduct a physical assessment of Pt 1. RN 1 stated, "[FNP 1] did not touch him" and felt FNP 1 "dismissed" the mother's concerns and reason for the visit. RN 1 stated she had witnessed this practice before, FNP 1 not completing a medical screening exam with other ED patients but had not reported it to management. RN 1 stated Pt 1 was directed after triage back to WR to wait for laboratory and ultrasound procedures. RN 1 stated Pt 1's father requested Pt 1 be given pain medication while Pt 1 waited for tests. RN 1 stated this "alerted" her since she had "clinical knowledge" of "autistic children" having high pain tolerance and was concerned Pt 1 "may have been in a lot of pain." RN 1 stated Pt 1's father was also "surprised" Pt 1 complained of pain. RN 1 stated Pt 1 was medicated for the pain and sent to a private ED room to have labs drawn. RN 1 stated Pt 1 was held down by his father and staff for labs to be collected. RN 1 stated Pt 1 was directed back to WR to wait after his blood was collected. RN 1 stated Pt 1 continued "yelling" in the WR and Pt 1's father requested that they be allowed to wait in their car. RN 1 stated the WR was full, and the family was allowed to wait in the car. RN 1 stated this was appropriate since the family parked outside the ED entrance and sat with their window rolled down. RN 1 stated the car was visible to the ED technician stationed in the WR. RN 1 stated "around 3 a.m." FNP 1 updated the "[ED] tracker board" (enables staff to track ED patients, pending orders, care being provided, and status of diagnostics studies and their results) to indicate Pt 1 was ready for discharge. RN 1 stated she had several patients to discharge so she tasked EDT 1 to print Pt 1's discharge instructions and RN 2 to complete Pt 1's discharge from the ED. RN 1 stated she "heard" RN 2 discharge Pt 1 and felt RN was a "newer nurse" with less ED experience. RN 1 stated she did not have time to "educate" RN 2 on ED protocols. RN 1 stated FNP 1 did not reevaluate Pt 1 nor discuss laboratory studies with Pt 1's family. RN 1 stated she did not review Pt 1's labs or ultrasound and assumed Pt 1 was stable for discharge since FNP 1 wrote discharge orders and Pt 1 "appeared to look better." RN 1 stated Pt 1's vital signs were not rechecked prior to discharge. RN 1 stated she was not aware of Pt 1's elevated WBC counts, elevated blood glucose, and glucose in urine. RN 1 stated she did not review Pt 1's laboratory and ultrasound results at any time on 11/30/23. RN 1 stated she was made aware of the "abnormal" results the next morning when she was notified by the EDM. RN 1 stated patients with Pt 1's similar symptoms and presentation would have been placed in a room and cared for in the "green zone" by two to three RNs; laboratory, radiological studies, and vital signs would have been assessed and documented more frequently. RN 1 stated in this case (Pt 1's visit) it was not done.

FNP 1 was placed on administrative leave effective 11/30/23 and was not available for interview.

RN 2 was not interviewed as she was on personal leave to care for a critically ill relative.

During an interview on 12/14/23, at 7:45 a.m., with the ED Charge Nurse (RN 3), RN 3 confirmed she was the charge nurse (oversee the operations of their specific nursing unit during a set period while working alongside the team) in the ED on 11/30/23. RN 3 stated the ED technician working on 11/30/23 informed her an "8- or 9-year-old-boy" with history of autism was in the WR and needed to be restrained to have labs drawn. RN 3 stated it was reported to her that Pt 1 had abdominal pain and was being worked up for an "Appy" (appendicitis- a pouch on the colon that becomes inflamed and filled with pus, causing pain). RN 3 stated she arranged a private room in the ED to have Pt 1's labs drawn. RN 3 stated it was not reported to her that Pt 1 was in distress. RN 3 stated she followed Pt 1 on the ED "tracker board" and confirmed Pt 1's labs and ultrasound were completed. RN 3 stated she reviewed Pt 1's labs, ultrasound, and vital signs and they were "nothing of concern." RN 3 stated she was not aware of what priority status (ESI score) was given to Pt 1 on 11/30/23. RN 3 stated it was not her practice to look at patients' ESI scores since the "number [score]" was for "billing and reimbursement" purposes. RN 3 stated she prioritized care based on the time and type of orders entered on the "tracker board." RN 3 validated RN 2 (medical surgical nurse) was "floated" to the ED department on 11/30/23 to assist RN 1 with assigned duties. RN 3 stated it was Hospital A's practice to "float" nurses to the ED during staff shortages. RN 3 stated RN 2 was instructed to medicate and discharge patients (within scope of practice) on 11/30/23. RN 3 stated RN 2 did not have access to the ED computer system and required assistance to access patient information.

During an interview on 12/14/23, at 8:15 a.m., with the EDD, the EDD acknowledged FNP 1 documented a MSE for Pt 1 on 11/30/23 and stated she was not aware FNP 1 did not conduct a physical examination on Pt 1. The EDD stated she was not aware that FNP 1 had a practice of not conducting physical examination of patients. EDD stated she was unaware RN 1 had observed FNP 1 not conduct physical examination on ED patients. The EDD stated the ED department had received two complaints from patients who came to the ED seeking emergent care alleging FNP 1 was "rude" and "did not do anything". The EDD stated "not doing anything" was interpreted by her as FNP 1 not meeting the expectations of the complainants. The EDD stated at the time she did not interpret the complaint to mean the FNP 1 did not conduct physical examinations. The EDD stated both complaints were escalated to the MED on 9/5/23.

During an interview on 12/14/23, at 8:50 a.m., with Pt 1's family member ( Mother), Mother stated she took Pt 1 to the ED on 11/30/23 to be evaluated for abdominal pain and constipation. Mother was tearful and stated, "They didn't do anything for him [Pt 1]." Mother stated Pt 1 was not evaluated by an ED physician and FNP 1 "never touched him [Pt 1]." Mother stated staff did not "listen" to her when she explained Pt 1 had history of autism and would require sedation for the ultrasound procedure. Mother stated Pt 1 was "screaming in excruciating pain" during the ultrasound and she voiced concerns to staff that a complete and accurate test would not be obtained. Mother stated Pt 1 remained in pain the entire ED visit. Mother stated he was medicated with "Motrin" when his blood and urine were collected but was not reassessed by the nurse nor offered additional pain medication during the visit. Mother stated Pt 1 was being loud because of his pain and they requested to wait in the car to avoid upsetting other children in the ED. Mother stated, while waiting in the car, staff did not assess Pt 1 nor reattempt taking vital signs. Mother stated she returned to the WR to inquire about lab results and was notified Pt 1 would be discharged. Mother stated she was told Pt 1 was stable to go home and to continue with fiber for constipation, no other instructions were provided. Mother stated she did not speak to FNP 1, and labs results were not reviewed with her. MOM stated after discharge, Pt 1 continued to have pain but fell asleep in a recliner next to his grandmother. Mother stated Pt 1 woke up sometime later stating his stomach hurt and requested water. Mother stated Pt 1 was given water and she returned to bed. Mother stated she was abruptly awakened to Pt 1's grandmother screaming and went to check Pt 1. Mother stated, "he had everything coming out of his mouth ... he was already gone ... I had just talked to him ... it happened so fast." Mother stated family in the home called emergency services, fire and police departments arrived within 10 minutes. Mother stated the police kept her in a separate room while emergency personnel attempted resuscitation and transported Pt 1 back to the ED. Mother stated Pt 1 was deceased by the time they arrived at the hospital. Mother stated she was informed by the sheriff coroner's office that Pt 1 had a "twisted intestine." Mother stated, "I didn't know," Pt 1 acted like he was constipated and so that's what was reported to the ED nurse when she sought emergent care for Pt 1. Mother stated she went to the ED on 11/30/23 and asked that Pt 1 be evaluated by an ED physician because Pt 1 was in pain and not getting better. Mother stated, "I tried."

During an interview on 12/14/23, at 9:45 a.m., with the Assistant Investigator of the County Coroner's Office (AICCO), the AICCO stated cause of death has not been established, however findings for Pt 1 included "Intestinal Volvulus" (a medical emergency that occurs when part of the colon or intestine twists, causing bowel obstructions that may cut off the blood supply and requires surgical treatment. Symptoms include abdominal pain and chronic constipation).

During an interview on 12/14/23, at 11:30 a.m., with the MED and the EDD, the MED stated he assumed the Medical Director ED role in August 2023. The MED stated, on 9/5/23, the EDD informed him of a patient who complained FNP 1 did not examine her daughter. The MED stated concerns (FNP 1's behavior and attitude) were discussed at that time with the ED physician's group regional leader and FNP 1. The MED stated it was decided to "start a paper trail" and develop a "PIP" (performance improvement plan) for FNP 1. The MED stated a second complaint was reported to him on 10/19/23 in which FNP 1 "was dismissive" of the patient's signs and symptoms during their ED visit. The MED stated FNP 1's dismissiveness was concerning to him and a meeting with human resources, physician group regional leader and manager took place on 11/8/23. The MED stated he was waiting for the "PIP" to be approved when the incident with Pt 1 occurred. The MED stated FNP 1 was immediately placed on administrative leave as a result and the leave was extended an additional 12 weeks. The MED stated he did not consider removing FNP 1 from the ED until 11/30/23. The MED stated he reviewed Pt 1's EMR and "overall [Pt 1] looked well" to all parties (FNP 1, RN 1, and MOM) during the first ED visit on 11/30/23 at 1:09 a.m. and Pt 1 was allowed to be discharged home. The MED stated FNP 1 had ordered "a good set of labs" and the ultrasound exam was "largely unimpressive." However, the MED stated Pt 1's WBC count (24,000 K/mm3) was concerning, and most concerning was Pt 1's blood glucose level (275 mg/dl). The MED stated clearly glucose was "spilling" into Pt 1's urine (UA- glucose > 500 mg/dl). The MED stated FNP 1 "missed" the elevated glucose levels and other symptoms that should have kept Pt 1 in the ED for further observation. The MED stated blood glucose level over 200 mg/ dl was abnormal and FNP 1 should have called (name of local Children's Hospital) for further instruction and possible transfer. The MED stated he did not agree with FNP 1's assessment of Pt 1 and decision to discharge Pt 1 from the ED on 11/30/23. The MED stated although pediatric patients were often discharged from the ED with elevated WBCs, the provider must discuss the weighted risks and benefits with parents and document the discussion in the EMR. The MED stated FNP 1's disposition was based on the department's "observation" of Pt 1 and not clinical findings. The MED stated FNP 1 did not follow the physician's group "Clinical APP [advanced practitioner provider] Guidelines" when Pt 1 was discharged from the ED on 11/30/23 with labs inconsistent with findings; Pt 1 "appeared well" but lab results did not coincide, therefore it was not clear, with certainty, whether Pt 1 had an emergency medical condition in need of immediate medical attention or stable enough to go be discharged home. The MED stated FNP 1 did not consult the supervising physician on 11/30/23 per guidelines.

During an interview on 12/14/23, at 3:35 p.m., with the EDM,