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Based on interview and record review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements when they did not provide an appropriate medical screening exam (MSE) for one out of 20 patients (Patient #1).

Patient #1, a four month old, arrived to the facility on 01/09/2024. A review of the patient's medical record revealed there was no patient history documented related to patient chief complaint of diarrhea, blood in the stool or Patient #1's dehydration status. The patient was discharged to the care of their gastroenteritis and subsequently admitted by the gastroenteritis on 01/09/2024 at 1440 PM, two hours and 28 minutes following his ED discharge on the same day. Patient #1 remained in the Hospital for 2.5 days. The admitting diagnoses included dehydration, irritability, and absence of tears.

Cross reference to Tag A2406 CFR §489.24(c).

Based on the record review and interviews, the facility failed to complete an appropriate Medical Screening Exam, within the capability of the Hospital Emergency Department for one of 20 patients (Patient #1) with medical emergency medical conditions, including dehydration and salmonella detection, before Patient #1 was discharged.
Patient #1 met with their gastroenterologist on the same day of the emergency room visit at Hospital A. The gastroenterologist directly admitted the patient to Hospital A, where the patient was treated as an inpatient for 2.5 days for a medical condition.

Findings included:

Record Review:

A review of Chart #1 at Facility A:

A review of the Emergency Department medical record (Chart #1) for Patient #1 revealed a four-month-old boy presented with "diarrhea since last night and noted blood in the diaper this morning."
The emergency department medical provider notes (MD Staff #1) on 01/09/2024 from 0956 AM - 1213 PM included the following: "Loose stools with increased volume and foul smell have been evident since yesterday ... mucus and blood streaks were observed in the stool ... Differential diagnosis includes but is not limited to infectious colitis, evolving IBD, intussusception, doubt bowel obstruction, less likely from anal fissure ... I am concerned about a severe complexity problem, evidenced by the differential noted above, and associated workup for bloody stools in the setting of fever, URI, and diarrhea, which is a new problem for this patient as evidenced by onset two days ago with progression."

A review of the Emergency Department medical record (Chart #1) for Patient #1 revealed there was no patient history documented related to patient chief complaint of diarrhea, blood in the stool or Patient #1's dehydration status.

A review of Chart #2 at Hospital A:

A review of documented provider history and physical notes by the Admitting Physician (MD Staff#2) for patient #1 on January 9, 2024, revealed that the admitting medical doctor identified several symptoms of dehydration in Patient #1, including irritability, decreased fluid intake, and the absence of tears.

A review of the medical record for Patient #1 from the Hospital Admission at Hospital A shows that Patient #1 was directly admitted by the gastroenterologist on 01/09/2024 at 1440 PM, just two hours and 28 minutes following her ED discharge on the same day. Patient #1 remained in the Hospital for 2.5 days. The admitting diagnoses included dehydration, irritability, and absence of tears.

The Assessment/Reassessment Procedure -Emergency Center: [Last revised 09/01/2022] stated that:
Vital Signs Policy: Vital Signs: A complete set of vital signs, including pulse oximetry and pain scale, should be obtained as appropriate for the patient's level of care.
Reassessment: This should occur upon arrival, every shift, or when there is a change of caregiver or status of the patient. It should also include the patient's vital signs and the Glasco Coma Scale. Abnormal vital signs should be reported to the provider before departure from the emergency center and documented in the Physician Communication Log.

The EMTALA POLICY -Emergency Center: [Last revised 09/01/2022] states that: The EMTALA Policy at Memorial Hermann mandates that all patients, regardless of payment method or insurance status, receive an immediate Medical Screening Examination (MSE) upon seeking emergency medical treatment. Stabilizing treatment must not be delayed for any reason.

Interviews:

During an interview with Hospital admitting Pediatrician MD Staff#2 on 02/06/2024 at 12:00 PM
"Q: What are the symptoms of dehydration for a 4.3-month-old baby?
A: Less than six wet diapers daily, Dry mouth and tongue, Sunken fontanelle, no tears when crying, Sunken eyes, Irritability and fussiness, Lethargy and drowsiness, Cool, clammy skin, Rapid breathing and heartbeat, Sunken cheeks, and abdomen.
Q: Did you see any of those symptoms in this baby when the patient was admitted?
A: Yes, a few. The baby was fussy, and the RNs complained of being unable to get an IV. There were no tears.
Q: In your opinion, Are these symptoms minor-moderate-severe?
A: Moderate, no matter what, because of the baby's age and mother's concerns, I would admit. MD Staff #1 must have admitted the patient."

During an interview with Staff #6 an emergency room Registered Nurse, on 02/06/2024 at 1155 AM, found that the patient was always crying in her care. Drinking little milk, fussy. We ran the fluids ASAP after establishing an IV. The mother is frustrated because the patient is cranky, and she is worried about the baby.

During an interview with Emergency Department Pediatrician MD, Staff #1 On 02/06/2024 at 01:35 PM
Q: Do you recall an incident involving a patient being discharged to the GI office who was a direct admit from the GI clinic?
A: Emergency department Pediatrician MD, Staff #1 recalls the patient incident and mentioned communicating with the patient's mother and the doctor for gastroenterology several times that day.
Q: Was there consideration for admitting the patient with dehydration?
A: Emergency department Pediatrician MD, Staff #1 mentioned that despite displaying stable vitals, the doctor for gastroenterology guided her to send the patient to his office.
Q: Is a 101.7 fever stable for a 4.3-month-old? Isn't this a sign of infection?
A: Tylenol 180mg Po was given before discharge.
Q: Can the gastroenterology doctor see patients in this Hospital?
A: Yes, he does and directly admits many pediatric patients. I believed it was the best course of action for the patient at the time, and the mother agreed with the care plan.
Q: Why did you not admit the patient instead of the doctor for gastroenterology?
A: According to the mother, the patient only had two blood-stained diapers, and Salmonella was detected after the patient left. Both the RN and I reported it to the GI doctor's office. The patient did not show signs of dehydration, was drinking milk, and remained calm and alert.