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Based on facility policy review, medical record review, and interviews the facility failed to provide stabilizing treatment for 1 patient (Patient #1) who presented to the emergency department (ED) of 31 ED patients reviewed.

The findings include:

Patient #1 presented to the ED on 4/30/2022 at 11:20 PM with complaint of lower legs with red spots and swelling. A medical screening exam was performed by a qualified medical provider on 4/30/2022 at 11:42 PM. A clean catch (a method of collecting a urine sample to be tested) urinalysis (UA-urine test) was collected on 5/1/2022 at 1:10 AM, resulted at 1:19 AM, and reviewed by the ED physician at 1:26 AM. The UA showed Patient #1 had nitrites (may indicate urinary tract infection), protein (in urine may indicate kidney disease), red blood cells (in urine may indicate urinary tract infection), white blood cells (in urine may indicate urinary tract infection), epithelial cells (large amount in urine may indicate infection), bacteria (germs), and mucus (may indicate a urinary tract infection) in the urine. The UA results were reviewed by a physician. There was no indication a prescription for an antibiotic was provided for Patient #1. Patient #1 presented to Facility B on 5/1/2022 at 5:17 PM (14 hours 47 minutes after departing Facility A's ED) with complaint of rash on lower legs and blood in the urine. The patient's UA and urine culture showed the patient had a Urinary Tract Infection and an antibiotic was prescribed. Patient #1 was diagnosed with Acute Purpuric Rash with Gross Hematuria and Arthritis consistent with Henoch-Schoenlein Purpura with Acute Glomerulonephritis and was referred to a Nephrologist (kidney doctor).

Refer to A-2407

Based on facility policy review, medical record review, and interviews the facility failed to provide treatment for a urinary tract infection (UTI) for 1 patient (Patient #1) who presented to the emergency department (ED) of 31 ED patients reviewed.

The findings include:

Review of Facility A's policy "emergency Screening Stabilization/Transfer/250 Yard Rule and EMTALA" last reviewed 3/2022 showed "...Purpose: To ensure that individuals coming to an affiliated hospital's dedicated emergency department seeking assessment or treatment for a medical condition, or coming to hospital property requesting (or obviously requiring) treatment for an emergency medical condition received an appropriate Medical Screening Examination...if an emergency medical condition is determined to exist, such individuals are offered stabilizing treatment within the hospital's capabilities and/or are transferred if appropriate...Emergency Medical Condition means...A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in...Placing the health of the individual (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...Placing the health of the individual...in serious jeopardy...Serious impairment to bodily functions; or...Serious dysfunction of any bodily organ or part...Stable for Discharge: A patient is considered stable for discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions..."

Medical record review of Facility A's ED Nurses Notes showed Patient #1 presented to the ED on 4/30/2022 at 11:20 PM with complaint of red spots and swelling of the lower legs which the patient's parents noticed on 4/29/2022. Patient #1 had been to an urgent care clinic and was told it may be chiggers and was provided a prescription for an antibiotic and steroids. Patient #1 denied pain. Patient #1 was triaged with an emergency severity index score of 4 indicating "...Semi-Urgent..." needs.

Medical record review of ED Physician (Physician Assistant) Documentation showed Patient #1 had a medical screening exam by a qualified medical provider on 4/30/2022 at 11:42 PM. The patient presented with "...rash and swelling to the legs..." Patient #1's mother reported they first noticed the rash on 4/29/2022 and reported the swelling had increased. Continued review showed Patient #1's family denied recent illness, fevers, chills, or recent medication changes. "...She [Patient #1] says the rash is a little itchy but not painful..." Patient #1's physical exam showed the patient had non pitting edema (swelling that does not indent when pressure is applied) of lower extremity to mid shin with purpura (red or purple discolored spots on the skin that do not blanch on applying pressure).

Medical record review of Physician Assistant (PA) #1 documentation dated 5/1/2022 at 12:42 AM showed Patient #1 presented to the ED for rash and lower extremity edema. "...Lab work ordered due to edema. Normal kidney function and slight elevated platelets..." Continued review showed PA #1 discussed the patient's case with Physician #1 who recommended not starting the antibiotic prescribed by an urgent care clinic but to start the steroids as prescribed by the clinic, and to follow-up with the patient's primary care provider on Monday (5/2/2022). PA #1 discussed returning to the ED if symptoms worsened with Patient #1's parents.

Medical record review of Patient #1's clean catch (a method of collecting a urine sample to be tested) urinalysis (UA-urine test) collected on 5/1/2022 at 1:05 AM showed the following:
*Color-yellow (reference range - yellow)
*Appearance-cloudy (reference range - clear)
*Specific gravity (test which shows how well kidneys diluting urine) was 1.025
(reference range - 1.001-1.035)
*PH (level of acid in urine) was 6.0 (reference range 5.0-8.5)
*Leukocyte (white blood cells may indicate infection) estimated-500 microliter
(uL) (3+) (reference range - negative)
*Nitrite (may indicate urinary tract infection) was positive (reference range -
negative)
*Protein (in urine may indicate kidney disease) 75 milligrams/ (per) deciliter
(mg/dl) (2+) (reference range - negative)
*Glucose (sugar)-negative (reference range - negative)
* Ketones (substances that your body makes if your cells do not get enough
glucose)-negative (reference range - negative)
*Urobilinogen (urine test for liver function)-normal (reference range - 0.2-1.0
mg/dl)
*Bilirubin (urine test for liver function)-negative (reference range - negative) *Blood-50 uL (3+) (reference range - negative);
*Red Blood Cells (RBC) 10-15/high power field (hpf) (reference range 0 - 1/hpf)
*White Blood Cells (WBC) 25-50/hpf (reference range - 0-1/hpf)
*Epithelial cells (large amount may indicate infection) 5-10/hpf (reference range -
none seen)
*Bacteria (germs)-moderate (reference range - negative)
*Mucous-moderate (reference range - none seen).

Medical record review of Patient #1's Disposition Summary showed the patient's discharge to home was ordered on 5/1/2022 at 12:11 AM (actual time was 1:11 AM according to ED Event timeline). Continued review showed Patient #1's discharge diagnosis was Other Vasculitis limited to the Skin.

Medical record review of an Order Sheet showed Patient #1's urinalysis results were reviewed by Physician #1 on 5/1/2022 at 1:26 AM.

Medical record review of Physician Documentation dated 5/1/2022 at 2:00 AM showed Physician 1 documented "...Family was refusing discharge after evaluation and treatment by [named PA]...[named PA] and I discussed patient's care and findings prior to her disposition of patient. Family stated that wanted to talk to 'the doctor'. I have counseled the patient's family that I am not immediately available to discuss patient's care with them at this time due to multiple critical care patient's in the Emergency Department at this time...Family made some snide remarks and indicated that they were probably going to leave and go somewhere else. I have counseled the patient's family that such is their right and that I would be available to them at my earliest convenience once critical patient's are stabilized if they decide to stay..."

Medical record review of Physician Documentation dated 5/1/2022 at 2:21 AM showed Patient #1 and the family left the ED prior to speaking with the physician.

Medical record review of an ED Nurses Note for 5/1/2022 at 2:25 AM (59 minutes after UA results reviewed by the physician) showed "...Patient's Father to the nurse's station requesting to speak with provider, was told by MD [physician] that he would be down as soon as he finished up with his critical patients. Patient's father upset and [told] staff he would be going to Children's Hospital. Left without discharge instructions or discharge vital signs..."

Medical record review of ED Nurses Notes showed Patient #1 departed the ED on 5/1/2022 at 2:30 AM (1 hour 4 minutes after urinalysis results were reviewed by Physician #1).

Medical record review showed no documentation to indicate a prescription for an antibiotic was provided for Patient #1.

Medical record review of Facility B's ED Medical Note showed Patient #1 presented to the ED with complaint of rash on lower legs and bloody urine on 5/1/2022 at 5:17 PM (14 hours 47 minutes after departing Facility A's ED). The patient had swelling of her legs and pain in her ankles. The rash was not itchy and was mildly painful. Further review showed Patient #1 had "...bright red blood in her urine today...She does have the joint pain primarily in her ankles only with edema at her ankles..." Continued review of Patient #1's physical exam showed edema of the lower legs with arthritis/arthralgias (pain) of both ankles. Purpura was present on both lower extremities.

Medical record review showed a urinalysis was performed for Patient #1 at Facility B on 5/1/2022 at 6:51 PM and showed the following:
*Urine Protein-593.3 mg/dl (reference range 0-11.9)
*Urine RBC >(greater than) 182/hpf (reference range 0-4)
*Urine WBC>182/hpf (reference range 0-4)
*Urine Transition Epithelial cell-moderate/hpf (reference range - none)
*Urine Bacteria 1+/hpf (reference range < (less than) rare)
*Urine mucus 3+/lpf (lower power field) (reference range *Urine Yeast (budding) 3+/hpf (reference range *Urine creatinine-182.5 mg/dl (reference range 0.5 to 1.0 mg/dl).

Medical record review showed Patient #1 was discharged from Facility B on 5/1/2022 at 8:29 PM with diagnoses including Acute Purpuric Rash with Gross Hematuria and Arthritis consistent with Henoch-Schoenlein Purpura with Acute Glomerulonephritis. Continued review showed Patient #1 had "...evidence of kidney inflammation/nephritis [A condition in which the tissues in the kidney become inflamed and have problems filtering waste from the blood] with blood, white blood cells in her urine as well as protein..." Further review showed Patient #1's case was discussed with a nephrologist (kidney doctor) and the patient's family was instructed to contact the Nephrology/Kidney Specialty Clinic the following morning (5/2/2022).

Medical record review showed a blood test for group A streptococcus bacteria was performed at Facility B on 5/1/2022; was verified on 5/2/2022 and showed a result of 800 IU (international unit)/ml (reference range 166-200 IU/ml) indicating Patient #1 had a recent strep infection. Continued review showed treatment with Cephalexin (antibiotic) 500 milligrams by mouth three times per day for 10 days was ordered for the patient.

Medical record review of a urine culture and sensitivity final report dated 5/3/2022 (collected 5/1/2022) showed Patient #1's urine was positive for Escherichia coli (bacterial infection).

During a telephone interview on 5/11/2022 at 7:00 PM, Patient #1's father stated "...[Facility A] missed it all together..." He reported Patient #1 was seen by a PA and was told to stop the antibiotic and continue with the steroids prescribed by an urgent care clinic. Continued interview revealed Patient #1 was taken to Facility B where she was diagnosed with a Urinary Tract Infection and Henoch-Schoenlein Purpura. Patient #1's father stated Patient #1 was not admitted to Facility B but she had been referred to a Nephrologist because it had affected her kidneys.

During a telephone interview on 5/11/2022 at 11:40 AM, PA #1 stated Patient #1 had an odd rash on her lower extremities, as well as swelling in the lower extremities. PA #1 stated she ordered lab work which showed the patient's kidney function was okay. Continued interview revealed Patient #1's urinalysis results were not back before the PA's shift was over. PA #1 stated she discussed Patient #1's case with Physician #1.

During a telephone interview on 5/11/2022 at 1:00 PM, Physician #1 stated Patient #1 had been seen by a PA and stated he had reviewed the PA's note, reviewed the patient's diagnosis and the treatment plan. Physician #1 stated he did not review the urinalysis results and he did not know a urinalysis had been performed. Physician #1 stated urine which was positive for nitrites would raise more concern for a possible urinary tract infection, but with no symptoms may question if the specimen was contaminated. Physician #1 stated he thought the "...plan for discharge and steroids was appropriate treatment for Vasculitis..."

During an interview on 5/12/2022 at 9:45 AM, in the conference room, the ED Director confirmed Patient #1's urinalysis results were reviewed by Physician #1 and the patient's Urinary Tract Infection (UTI) was not treated.

During a telephone interview on 5/12/2022 at 3:10 PM, the ED Medical Director stated he thought Patient #1 was probably in a Henoch-Schoenlein Purpura situation. The ED Medical Director stated if that was the case then steroids would have been correct. The ED Medical Director stated "...an antibiotic should have been prescribed for the UTI...if she was still there [in the ED]..."