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Based on medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for one of 20 (Patient #1) sampled patients who were eighteen years of age or younger.

The findings included:

Medical record review revealed Patient #1 was an 8-year-old male who presented to the Hospital #1 Emergency Department (ED) on 12/14/2023 at 9:46 PM with a chief complaint of Seizures. Patient #1 had a medical history of Trisomy 21, Epilepsy, and Gastrostomy Tube (G-tube) Dependence.

Patient #1 started having seizures approximately every 5 to 10 minutes on the afternoon of 12/14/2023. The seizures lasted for approximately 10 seconds. The patient had stiffening of the body. Patient #1 was seen by ED Physician #3 who documented Patient #1 had two brief seizures during triage and another brief seizure during the physical examination, but the physical exam was otherwise unremarkable. ED Physician #3 ordered a basic metabolic panel (checks for the levels of glucose, calcium, bun-urea-nitrogen, creatinine, sodium, potassium, chloride, and carbon dioxide in the blood) which revealed a glucose level of 56 (normal fasting blood sugar level is 60 to 90). There was no documentation of interventions to treat Patient #1's low blood sugar level . There was no documentation the blood glucose level was reassessed while Patient #1 was in the ED. Patient #1's hypoglycemia was not fully and appropriately re-assessed.

ED Physician #3 did not order a urinalysis to check for possible occult infection.

Refer to A 2406

Based on medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for one of 20 (Patient #1) sampled patients who were eighteen years of age and under.

The findings included:

Medical record review revealed Patient #1 was an 8-year-old male who presented to the Hospital #1 Emergency Department (ED) on 12/14/2023 at 9:46 PM with a chief complaint of Seizures. Patient #1 was brought to the Hospital #1 ED by his parents by private vehicle. Patient #1 had a medical history of Trisomy 21, Epilepsy, and Gastrostomy Tube (G-tube) Dependence.

Patient #1 was triaged at 9:53 PM and was assigned a patient acuity of 2 (high risk situation).

Patient #1's parents reported Patient #1 had a baseline of 1-2 seizures per month, but Patient #1 started having seizures approximately every 5 to 10 minutes since earlier that afternoon (12/14/2023). The seizures lasted for approximately 10 seconds with stiffening of the body. The parents reported Patient #1 had been more tired today (12/14/2023) and had not been sleeping well but was otherwise at his baseline. Patient #1 had been tolerating tube feedings through his G-tube without vomiting.

Patient #1 was seen by ED Physician #3 at 10:08 PM. ED Physician #3 (5th year resident) documented Patient #1 had 2 brief seizures during triage and another brief seizure during the physical examination. The seizure during the physical examination was tonic in nature with full body stiffening and lasted approximately 10 seconds. ED Physician #3 documented the parents reported that Patient #1 appeared somewhat tired but was otherwise at his neurologic baseline. ED Physician #3 documented Patient #1's physical exam was otherwise unremarkable. ED Physician #3 ordered a basic metabolic panel (BMP), complete blood count with differential, and a hepatic (liver) function panel at 10:29 PM. The BMP was resulted at 11:57 PM with a glucose level of 56 (reference range was 60-90). The ED Physician #2 signed on 12/16/2023 at 6:54 AM that he saw and evaluated Patient #1, and he discussed the care with ED Physician #3 and agreed with the findings and plan.

There was no documentation Patient #1's below normal glucose level was ever reassessed or treated. There was no documentation Patient #1 was given any food or feedings through the G-tube to address the low blood sugar. Patient #1's hypoglycemia was not fully and appropriated assessed.

ED Physician #3 did not order a urinalysis to check for possible occult infection.

ED Physician #3 documented Patient #1 was discharged home, with the parents, on 12/14/2023 at 1:02 AM and documented she had a detailed discussion with the patient/parents about Patient #1's symptoms, workups, what to look out for, and when to return to the emergency department.

Review of an Internet search revealed the patient lived 131.3 miles from Hospital #1 (over 2 hours travel time). This would have made it difficult for Patient #1 to return to the ED quickly and seek care. There was no documentation by ED Physician #3 or Pediatric Neurologist #1 that they were aware of the distance Patient #1 would have to travel to return and seek care.

Patient #1 returned to the Hospital #1 ED on 12/15/2023 at 12:26 PM with the chief complaint of continuing seizures every 3-5 minutes lasting approximately 8-10 seconds each. Patient #1 was admitted to Hospital #1 for further evaluation and treatment. The parents reported that they were unable to pick up the Keppra medication since the local pharmacy was out of stock. The parents reported Patient #1 started having seizures at some time after 9:00 AM (12/15/2023), and they brought him back to the Hospital #1 ED.

Patient #1's respiratory pathogen panel was positive for rhinovirus/enterovirus. Patient #1's hospital course was complicated by Strep pneumoniae and Methicillin-resistant Staphylococcus aureus (MRSA) tracheitis requiring antibiotics. Patient #1 continued to have seizures during his hospital stay. The Rapid Response Team (team of medical providers who intervene when a patient demonstrates signs of imminent clinical deterioration) responded to Patient #1 demonstrating near continuous seizure activity on 12/16/2023 at 9:03 PM. Patient #1 was then transferred to the Pediatric Intensive Care Unit for closer observation and treatment. On 12/18/2023, Patient #1 began to demonstrate increased work/difficulty in breathing and was intubated with pressure regulated volume control. Patient #1 gradually improved and was extubated on 12/24/2023. Patient #1 continued to improve and was discharged home on 12/26/2023.

In an interview on 1/10/2024 at 10:55 AM, Registered Nurse (RN) #2 confirmed she was the primary nurse for Patient #1 during his ED visit on 12/14/2023. RN #2 stated Patient #1 was still altered from the medications he received at home when he was placed on the monitor (cardiac). RN #2 stated the parents reported Patient #1's seizure activity had increased, and he was having seizures approximately every 5 minutes. RN #2 stated neurology was consulted, and they ordered a loading dose of Keppra. RN #2 stated there were no further seizures witnessed or reported after Patient #1 received the Keppra medication. RN #2 stated she accompanied the ED physician into Patient #1's room to go over the discharge plans. RN #2 stated the parents were comfortable with the return instructions given and the discharge home. RN #2 denied that Patient #1 exhibited any signs or symptoms of infection or other illness.

In an interview on 1/10/2024 at 11:53 AM, RN #4 confirmed she was the triage nurse for Patient #1 during his ED visit on 12/14/2023. RN #4 stated she recognized Patient #1's name, and his triage, "was a very short interaction. The parents brought him in with seizures, and the parents had already given him 3 prns [as needed medication for seizures]. He did have a seizure in triage area, so I called my charge nurse and told her we needed to get him to the back pretty quickly ..."

In an interview on 1/10/2024 at 12:32 PM, ED Physician #2 confirmed he was the medical provider for Patient #1 when he presented to the Hospital #1 ED on 12/14/2023. ED Physician #2 stated Patient #1 had a complex medical history most notable for seizure activity. ED Physician #2 stated the reported history and what was observed in the ED were very short cluster seizures. ED Physician #2 stated Patient #1 "had no fever, no symptoms reported on exam, there was no evidence of an illness."