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Based on review of documentation and interviews with facility staff, the facility failed to provide an appropriate and thorough medical screening examination within the capability of the hospital's emergency department to determine whether an emergency medical condition existed for 1 of 21 (Patient #1) patients reviewed that presented to the emergency department (ED). Patient #1's VP shunt was not examined and evaluated for shunt infection after coming to the ED complaining of fever, vomiting, and fussiness.

The complete medical record of Patient #1's first ED visit on 9/24/23 was reviewed. It was noted:

Patient #1 was brought to the ED for vomiting. Patient #1 had a past medical history of spina bifida and a past surgical history of ventriculoperitoneal (VP) shunt placement. Initial vital signs showed Patient #1 had a fever (103.2 F) and a fast heart rate of 194 beats per minute. Patient #1 had multiple laboratory and diagnostic tests performed. The urinalysis came back abnormal and Patient #1 was diagnosed with a bacterial urinary tract infection. Patient #1 was discharged to home with a prescription for oral antibiotics.
There is no documentation to indicate that the ED physician evaluated the patient's VP shunt during examination. There is no documentation to indicate that a pediatric or neurosurgical consult was performed to address a differential diagnosis of shunt infection. There is no physician order to assess the patient's blood for contamination of microorganisms [sepsis]. There is no repeat temperature assessment after administration of Tylenol or prior to discharge.


1. ED Nursing Note: "Chief Complaint: Shortness of breath (Pt [patient] mother states that the patient had an episode this afternoon of 'gurgling' and states her feet turned purple. Reports pt appears back to baseline but seems tired. 98% on RA [room air]. 103.2F rectal temperature in triage."

2. ED Provider Note: "Patient with a PMHX [past medical history] of spina bifida and ventriculoperitoneal shunt presents to the ED with one episode vomiting ... She is fussy throughout the exam but is easily consoled. Work-up does reveal bacterial UTI but discussed this at length with mom. She had fever initially which was treated and has resolved ... Multiple differential diagnoses were considered in this patient based upon history, physical exam, and workup. These include Shortness of breath, asthma exacerbation, COPD exacerbation, pneumonia, viral illness, pulmonary embolism, acute coronary syndrome, traumatic injury, pneumothorax, anxiety, panic attack, among others. and sore throat, viral pharyngitis, bacterial pharyngitis, anaphylaxis, angioedema, epiglottitis, peritonsillar abscess, Ludwig's angina, retropharyngeal abscess, deep space infection, foreign body, trauma, mass tumor."


3. Vital Signs (ED Care Timeline)
1304: Temp 103.2 F (rectal); Heart Rate 194; Resp 40; SpO2 98%; Pain Assessment: Hurts little bit
1331: Heart Rate 165
1426: Heart Rate 143; SpO2 96%


The surveyor interviewed Staff #7 (the initial ER physician that took care of Patient #1 on 9/24/23) on 11/28/23 via telephone. Staff #7 recalled that Patient #1 was "fussy but interactive" and that vital signs were "better at discharge" but could not recall what the vital signs were. Staff #7 stated that there was no need for transfer or that the patient required a higher level of care that was provided in the ED.

Patient #1 was seen at the facility's other ED location approximately eight hours later for skin discoloration, chills, labored breathing, cough, and vomiting. Blood test revealed elevated white blood cell count and lactate levels. Patient #1 was admitted by pediatric service for urinary tract infection and sepsis. Patient was hospitalized for three days and received IV antibiotics.