HospitalInspections.org

Based on review of documentation and interviews with facility staff, the facility failed to provide an appropriate and thorough medical screening examination (MSE) within the capability of the hospital's emergency department, including neurology consultation available to the emergency department, to determine whether an emergency medical condition (EMC) existed for 1 of 21 (Patient #1) patients reviewed that presented to the emergency department (ED). Patient #1 presented to the ED a second time for ongoing dizziness with additional symptoms of decreased facial sensation, slow to stand, and shortened steps with shuffling gait. The patient had a CT head completed and was negative. No neurology consultation was obtained by the ED, and the patient's symptoms did not resolve prior to being discharged home. The patient was seen at a different ED four days later, received an MRI and was diagnosed with a tumor on the medulla and brainstem, which required surgical intervention.

The findings were:

Patient #1's medical record from Hospital A was reviewed, it was noted:
Patient #1 was initially seen on 7/19/23 complaining of nausea, vomiting, and dizziness. Patient was diagnosed with acute gastritis and dehydration, discharge to home with referral to gastroenterology. Patient #1 was seen at the ED again on 7/23/23 and "presents with dizziness x7 days. Pt reports having headaches that come and go, but feels dizzy 'all the time', and worse when standing up. She notes that it feels like 'room is spinning all the time', mom also report that pt has to hold walls/ someone's hand to walk as she does not feel stable at all. Pt feels tingling on legs and arms starting this morning, and fells nauseous every morning. Nausea every morning, and vomits in morning occasionally, last 2 days ago." The ED physician's physical exam noted, "NEURO: A&Ox3, follows commands, normal tone/strength, No focal deficits, moving all extremities well, clear speech, CN 2-12 intact except pt reports decreased sensation to left side of face but intact facial motor CN7 bilaterally, motor 5/5 strength upper and lower extremities bilaterally, negative Romberg, slow to stand, shortened steps with shuffling gait, holding on to person/object for balance due to vertigo dizziness (room spinning) 2+ dtr bilateral Patella and Achilles bilaterally, no nystagmus." A CT Head without contrast was performed and the impression indicated, "No intracranial abnormality." Patient #1's final diagnoses were "dizziness and giddiness" and "nausea." Patient #1 was discharged to home with meclizine and a referral to neurology. The patient's symptoms did not resolve prior to being discharged home. No documentation indicate that neurology was consulted by ED physician. Review of the neurology on-call schedule for 7/23/23 to 7/24/23 indicated at least two neurology physicians (resident and attending) were available for consults. The neurology consult could have assisted the ED physician in determining need for admission and further testing or discharge with prompt follow-up with neurology.


The surveyor interviewed Staff #8 (ED physician that took care of Patient #1 on 7/23/23) via email on 9/19/23:
Surveyor: What do you remember about this particular patient?

Staff #8: "Initially off hand, I did not remember the case in my memory. After review of my note of the encounter on 7/23/2023 I remember the encounter well, including the presenting symptoms and exam which are well documented in my note. As documented, I remember her most prominent complaint was "dizziness" in addition to the associated symptoms mentioned. Her neurological exam was as documented, but remember there were no clear neurological deficits, including cranial nerves as tested, but she reported the sensation change on her face. She was slow to stand and reported the "room was spinning" but she did not display ataxia or other concerning neurological deficits. The differential diagnosis and plan are documented in my note as I remember. I also remember the results discussion with the family. We discussed all results including the slightly abnormal ESR but no other signs of infection. We also discussed the CT scan results, with no intracranial abnormality, and with no acute emergent abnormality identified she did not need to be admitted to the hospital but that further work up of dizziness and headaches could be completed on an outpatient basis. But due to the persistence of symptoms I also recommended Neurological consultation and follow up with neurology. I also provided a trial of meclizine to determine if this would provide symptom relief and inform further workup at the neurology clinic. I remember the parents being in agreement with this plan and I don't recall them expressing any dissatisfaction at that time."


Patient #1's medical record from Hospital B was reviewed, it was noted:
Patient #1 was seen at the ED of Hospital B on 7/27/23 complaining of "difficulty walking, can't keep balance, double vision and room spinning." The ED physician consulted the on-call pediatric neurologist "who recommended admit, MRA and MRI of head without contrast ... Results came back revealing expansile mass involving medulla and adjacent brainstem on the left side likely representing a brainstem glioma." Patient #1 had a posterior fossa craniotomy for medullary tumor biopsy performed and also had a G-tube placed during admission. Patient #1 was treated in the pediatric intensive care unit with high-dose dexamethasone and eventually discharged on 8/24/23 to home with outpatient therapies.