HospitalInspections.org

Based on observation, a review of documentation, policies and staff interviews, Facility A failed to provide a medical screening exam in the emergency department to determine if an emergency medical condition existed. Patient # 1 had bloody emesis in the emergency department lobby. Patient #1 left facility A after being informed they did not have a specialist for Patient #1. Patient #1 went to facility B where they was seen in the ED and diagnosed with "Post-tonsillectomy hemorrhage" and was admitted.

Findings Include:

Record Review

Quality Summary Report for Facility A: Arrival time of 01/19/2024 at 9:53 PM. Discharge status: "08 Not Documented or unable to Determine (UTD)". Discharge time 01/19/2024 at 10:03 PM, Discharge Status: 08: Not Documented or Unable to Determine (UTD) principal. Diagnosis: Missing. Admission Complaint: None. No additional documentation was generated at arrival by staff.

A review of the document titled " ED Provider
Note" by Facility B, Staff # 1, MD-ED on
01/28/2024 at 8:02 AM revealed the following:
"Her mother states that she had a tonsillectomy
and adenoidectomy on 01/05, performed by Dr.
Saadeh. The patient has been tolerating food and
feeling well since her procedure. However, she
had 1 episode of coughing up blood yesterday.
Earlier today, the patient had an episode of
hematemesis prompting the visit to the ED. Her
father states that she felt like there was a scab at
the back of her throat. She was coughing pretty
hard when she ended up vomiting blood." A
review of Systems included: Positive for cough,
positive for vomiting and positive for dizziness.

Patient #1 was diagnosed with "Post-tonsillectomy hemorrhage" and was
admitted to Facility B on 01/20/2024 at 12:52 PM.
The patient had a "tonsillectomy post OP bleed
control" completed on 01/20/2024 at 9:52 AM.
The patient was discharged home on 01/20/2024
at 8:00PM.

A review of the policy titled "PC 033 Emergency Medical Treatment and Labor Evaluation" revealed the following: page 3
POLICY:
1. "Any individual (including a minor child and/or infant) who presents to any Methodist Health System (MHS) facility requesting assistance for a potential Emergency Medical Condition (EMC) or is in labor will receive a Medical Screening Examination (MSE) by a Qualified Medical Provider to determine whether an EMC exists."

A review of the policy "PC 155- Pediatric Admissions" revealed the following: page 2
"ATTACHMENT A: Pediatric Admissions Addendum (MDMC)
1. Pediatric Guidelines for Emergency Services:
A. Pediatric medical admission in the ED:
o Patients 17 years and younger needing medical admission should be transferred to Children's Medical Center by calling the Pediatric Hotline.

Interviews

A phone interview with Staff # 3, Paramedic on 02/26/2024 at approximately 3:30 PM revealed the following:
Surveyor: Did you meet with the patient and her father?
Staff # 3: I can't remember if it was the Mom or Dad. They came to the desk and I think it was the Mom who took the patient and I spoke with the father. The father said the child had a tonsillectomy. I finished my notes and the triage nurse took the next patient into the triage room. The father came up to me and asked for an emesis bag. I saw the child was throwing up blood. The nurse came out, staff # 4, and said we can do all we can and will have to transfer her to children's hospital. If anything else was said, I couldn't hear it.
Surveyor: Did you get vital signs on the child?
Staff # 3: No, I called for her but she was in the bathroom with her mother.
Surveyor: Was the ED busy that night?
Staff # 3: Yes, it was busy. I also remember we were waiting for a few patients to transfer out. After the family left a few more patients came to the desk to sign out AMA saying they weren't as sick as others.

A phone interview with staff #4, RN, Charge Nurse-ED on 02/27/2024 at approximately 8:30 AM revealed the following:
Surveyor: Are you aware why I am calling?
Staff # 4: Yes, my supervisor told me you would be calling and reminded me about the case.
Surveyor: Can you tell me about you involvement in the case?
Staff # 4: I was called to the front, we were very busy that night, I was asked to take a first look at the patient. She was not triaged at that point. I asked her to open her mouth and I saw red saliva and scabbed areas where her tonsils were removed. I asked where the patient had her tonsils removed and was told in the HEB area. I said we are happy to see her and check her in to see a provider, there is a chance that we will have to transfer her because we don't have an ENT or Pediatric specialist and her tonsils were removed elsewhere. The father asked if the facility did not treat Pediatrics. I told him we work with all ages but we have to transfer out for certain services. The father asked me what I would recommend. I told him, "I can't advise you." The parents discussed things for a while and the father said they were going to take her to a pediatric hospital. I gave them an emesis bag and tissues as they left.
Surveyor: Was the doctor made aware of this patient?
Staff # 4: No, the provider was not made aware.

A phone interview with the Father of the patient on 02/27/2024 at approximately 8:45 AM revealed the following:
Surveyor: Can you tell me what happened the night you brought your daughter to Methodist Midlothian Medical Center?
Father: My daughter had her tonsils removed a week prior. My daughter said that" it feels like a scab came off in my throat." I looked at her throat and it looked normal for having her tonsils removed, about an hour later she said it feels like there is "blood draining down my throat." I looked again and it was. I called the surgeon and was told to take her to the nearest ER. While we were waiting in the waiting room, my daughter said she felt like she was going to throw-up and she did. "It looked bad, all red." I went to get something to clean it up. We were 15 feet from the front desk. A nurse comes out and said, honestly, we don't have ENT or Peds here and she needs help now. If we take her back now and start a transfer because we don't have the specialists to care for her, it will take a long time. We left and I drove about 100 miles an hour. My daughter had emesis x 3 on the way and I had to carry her in. It seemed like she was hallucinating. They gave her something for the emesis and an IV bag. She seemed to come around and no more emesis.
Surveyor: Did you ever see a doctor at Methodist Midlothian Medical Center?
Father: No, we did not.

An interview with Staff # 3, Chief Nursing officer (CNO) on 02/27/2024 at approximately 10:10 AM revealed the following while in the ED:
Surveyor: What is the title of the person sitting at the front desk?
CNO: She is an RN.
Surveyor: Does a unit clerk or Tech ever sit at the desk?
CNO: A paramedic will sit with the RN but the paramedic would not be scheduled there alone.
Surveyor: When a patient arrives at the desk, are they asked for their insurance?
CNO: No, there is a form we ask them to fill out and this is when we first lay eyes on them.
Surveyor: If a patient arrives without insurance, what do you do?
CNO: We care for all patients that arrive at our hospital. We have a large Charity Department.
Surveyor: When is the patient asked for their insurance information?
CNO: After the doctor sees them.
Surveyor: Can you explain how a patient's insurance information could appear on a chart if the patient left before being triaged?
CNO: The only way that could happen is when the information is entered into the computer from the slip of paper and the patient was seen at any epic location, insurance information would be automatically generated into the chart.

An interview with Staff 5, Patient Access Registration on 02/27/2024 at approximately 10:35 AM revealed the following:
Surveyor: When do you first meet with the patient?
Staff 5: After the patient is seen by the doctor.
Surveyor: Do you ask the patient for their insurance information?
Staff # 5: Yes, I do.
Surveyor: If a patient leaves without being seen by the physician, would you see them to register?
Staff # 5: No, I would not. I only see patients after the doctor has seen them.

An observation of the security tape on 02/28/2024 at approximately 12:45 PM revealed on 01/19/2024 from 9:56PM to 9:59PM the Patient and Parents sitting in the ED until they left the facility.
On 9:56 PM the family in is the ED, sitting in chairs with their backs to the camera. The patient tilts her head forward. Her father gets up and walks off camera and returns with something in his hand. The RN-ED, staff # 4 came over to the patient and used a flashlight that was shining to the patient's face. The RN-ED is talking (no audio) with the father and then the family stood up and moves to the exit door. As they were leaving Staff # 4 handed the family an emesis bag. Family departs at 9:59PM.



A review of the document titled "Op Note" by Staff #2, Facility B, MD on 1/20/2024 at 9:25 AM revealed the following:
..."INDICATIONS: The patient is brought to the operating room today for Procedure(s):
TONSILLECTOMY POST OP BLEED CONTROL to treat Pre-Op Diagnosis." ... "DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room where general endotracheal anesthesia was performed.
A Crowe-Davis mouth gag retractor was placed intraorally and suspended from a Mayo stand. The right upper half of the tonsillar bed had clot that was gently suctioned. There was no specific arterial or venous bleeder, had some mild ooze from surrounding granulation tissue. Granulation tissue was cauterized with suction cautery. The retractor was released and resuspended and the tonsillar bed was massaged and no additional bleeding was noted. Several passes of OG tube to suction the stomach was performed. No evidence of any blood in the stomach, completely clear fluid no evidence of coffee-grounds. The patient was then transported to the recovery room in stable condition."

Discharge noted: "No further bleeding and the patient was cleared by ENT."