HospitalInspections.org

Based on record review and interview the facility failed to ensure all patients who enter the facility's emergency room seeking care and treatment names are recorded in the facility's emergency room Log In 1 of 1 Patient. Patient #1

Findings:

Emergency Room visit of 01/29/2022
There were no emergency room records found on Patient #1.

Review of the Facility's Emergency Room Central Registration Log dated 01/29/2022 revealed there was no documentation of Patient #1's visit to the facility's emergency room .
However, the Surveyor requested to view recording from a camera mounted in the lobby of the emergency room.

On 02/09/2022 at 08:00 a.m. the Surveyor viewed the recording of the camera with the Facility's Director of Quality present which indicted the Patient was brought to the emergency room on 1/29/2022.

Registered Nurse (#56)
Interview on 02/08/2022 at 10:56 a.m. with Registered Nurse (56) revealed, while working in the emergency room on 01/29/2022 she saw a mom holding the baby wrapped in a blanket in the lobby of the emergency room.
She said the Patient's mother told her that the baby had not been eating well and was lethargic. She obtained the patient's name and date of birth from the mother and then went and told Physician (#58) about the Patient.

Based on observation, record review and interview , the Facility's Governing Body failed to ensure an emergency medical screen was conducted on 1 of 1 patient who presented to the facility's emergency room requesting service. Patient #1

Findings:

Patient #1
An investigation was conducted at the above facility as a result of a complaint regarding Patient #1 ( a baby) who was brought to the facility emergency room by a parent on 01/29/2022.

Emergency Room visit of 01/29/2022
There were no emergency room records found on Patient #1.

Review of the Emergency Room Central Registration Log dated 01/29/2022 revealed there was no documentation of Patient #1's visit to the facility's emergency room.
However, the Surveyor requested to view recording from a camera mounted in the lobby of the emergency room.

On 02/09/2022 at 08:00 a.m. the Surveyor viewed the recording of the camera with the Facility's Director of Quality who was present.

Review of the video without sounds revealed the following:
On 01/29/2022 at 15:25 p.m.: Two individuals entered the lobby of the facility and approached someone from at the registration desk. One of the individuals had a bag over her shoulder and something in her arm. A clipboard with papers were handed by the person behind the registration desk to the individual with the bag over her shoulder.

15:27 p.m.: A male individual wearing teal-colored scrubs (identified by the Facility's Quality Director as a physician) came out of the inside of the emergency room to the lobby and approached the individual who was given the clipboard. A female wearing green scrubs (identified by the Facility's Quality Director as a nurse), came to the door leading to the lobby and remained standing at the door while the male individual in teal scrubs approached and dialogued with the individual who was given the clipboard.
The individual in the teal scrub who was identified as a Physician was observed speaking to the individual who was given the clipboard. They both had a running dialogue and gesticulated while communicating. The blanket was pulled back and the physician was seen touching a baby who was wearing a pink hat.

15:29 a.m.: After dialoguing with the Physician, the individual who was given the clipboard returned the clipboard to the registration desk and both individuals who had entered the lobby with the child wrapped in a blanket left the lobby of the emergency room at 15:29 p.m. There was no audible sound on the camera recording, so the Surveyor was not privy to what was said between the two parties.

Interviews:

Registered Nurse #59
Interview on 02/08/2022 at 10:50 a.m. with the Facility's Emergency Room Manager Registered Nurse (# 59) revealed, she was not present in the facility during the Patient's visit to the emergency room, because this happened on a Saturday. She said she was made aware that the mother presented to the emergency room with the baby and spoke to Registered Nurse (#56), the Registered Nurse who was on duty. She said Registered Nurse ( #56) spoke to Physician (#58) who was present and working in the emergency room. The Physician went to the door and spoke to the patient's mother, but he did not conduct a Medical Screening Exam (MSE). He told the patient's mother that a pediatric hospital would be best. She said when the nurse returned to the lobby the mother and patient had left the facility.

She said since she was notified of the incident the entire staff was retrained on EMTALA, and triage, but this did not include the physician who was present during the incident, but the Medical Director spoke with the physician.

Registered Nurse (#56)
Interview on 02/08/2022 at 10:56 a.m. with Registered Nurse (56) revealed, while working in the emergency room on 01/29/2022 she saw a mom holding the baby wrapped in a blanket in the lobby of the emergency room.
She said the patient's mother told her that the baby had not been eating well and was lethargic. She obtained the patient's name and date of birth from the mother and then went and told Physician (#58) about the patient.

She said the doctor went into the lobby to see the patient because there were no beds immediately available. She said while the doctor was in the lobby speaking to the patient's mother, she said she heard the Physician telling the patient's mother that if she takes the baby to a pediatric hospital, they will see the baby right away, because he guarantees that the baby did not look this way when the baby was taken to #3 Children's Hospital.

She said the patient's mother asked the doctor, "should I call an ambulance?" and the doctor told the patient's mother, "no if you call an ambulance the patient would be brought right back to the hospital door." She said the mother then walked out of the facility with the baby.

She said from where she was standing in the emergency room, she saw the Physician "poking at the patient's cheek."
Registered Nurse (#56) said, when the Physician returned to the desk he stated: "The baby is cooing they will make it." She said the Physician, also said when the mother of the patient called the patient's pediatrician she was told to go to a pediatric hospital.

Registered Nurse (#56) said the mother had the baby wrapped in a blanket, but when she saw the patient in the mother's arms and was told the baby was lethargic, she had concerns and so that was the reason why she immediately called the doctor, so he could examine the baby and put the baby in one of the trauma rooms.

Interviewed the Patient's Mother

Interview via the telephone on 02/08/2022 at 9:33 p.m. with mother of Patient #1 revealed, she stated that she went to the hospital with her sister and her baby. She stated "I went in and told them I needed help with my daughter. They buzzed me in, and I spoke to a lady at the front, who gave me papers to fill out. I started to fill it out. The lady left and called the doctor. A doctor in a green/blue scrub came out. I told him that we were back and forth at the doctor and she was coughing all week. We had gone to #2 Children's Hospital before and was told she had a viral infection also went to #3 Children's Hospital." She said she told the doctor that the baby was "not doing anything and was grey looking." She said the doctor looked at the baby, touched her and then told her to go in her car and drive as fast as she could to a pediatric hospital. She said she asked the doctor to treat the baby. She also asked him if it wouldn't be faster to call an ambulance. The doctor said no, but the lady at the desk said yes and the doctor said something to the lady which she did not hear.

She said she left the facility and pulled over at her house to get her husband. She also called the patient's Pediatrician and told her that she did not feel safe and if it was ok to go to the EMS station. The Pediatrician instructed her to pull over and call 911.

She said when 911 arrived, she handed the baby to the EMT paramedic who called for assistance. She said she was driven to La Grange and while in the ambulance the paramedic was constantly bagging the Patient until they got to La Grange. She said the patient was then life flighted to #2 Children's Hospital.
She said she did not accompany her daughter during life flight but when she reached the hospital her daughter was intubated.


Interviewed Emergency Room Physician (#58)
An interview was conducted via the telephone with Emergency Room Physician (#58) The Facility's Medical Director was present during the interview.
Interview on 02/09/2022 at 11:15 a.m. via the telephone revealed Physician (#58) stated "I saw that there were a couple of people present so I went out to the lobby to see what I could do. A woman said, "I need you to see my child." I was told she went to #2 Children's Hospital before and so she called her Pediatrician who told her to take the baby back to #2 Children's Hospital. "
Physician (#58) said the mother wanted a second opinion of what was told to her by her daughter's Pediatrician, and so that was the reason she brought the child in.

He said the mother asked how long it will take to get to #2 Children's Hospital. He said the child was moving when he was next to the patient's mother. He said the mother asked about transportation and he told her he could not tell her about transportation.
The Surveyor notified the Physician that there was no evidence of an MSE documented by him. Physician (#58) said he wanted to make sure he had consent from the patient's guardian to provide care to the child. He denied telling the patient's mother to take the baby to #2 Children's Hospital. The Surveyor informed him that the nurse who was present during his interaction with the patient's mother, validated that he told the patient's mother that if she took the baby to a pediatric hospital, they would see the baby right away.

He said due to electronic medical record in use by the facility, and not getting assistance with accessing the system, an encounter with the patient was not entered or documented.

Reviewed Document from #2 Children's Hospital Emergency room:
Review of the Patient's record revealed the following documentation from Hospital #2 Children's Hospital
Triage
"Mode of Arrival, ED: EMS Air, Stretcher at 17:14 p.m.
Admitted/Transferred From: No
Hx of Present Illness/Mech of Inj /Onset: Pt with increased WOB over last few days today with apnea episodes. Enroute here pt had episode of bradycardia with EMS with HR dropping to 50's and sats to the upper 60's
Abuse/Neglect Screen: No
Visit Precipitated
Visit Reason: RESPIRATORY DISTRESS
Tracking Acuity: 2 - Emergent
Information Given By: EMS
Treatments Prior to Arrival: Other: IO and 80 ml NS bolus
Vitals
Temperature Rectal: 94
Peripheral Pulse Rate: 176 bpm
Respiratory Rate: 42 br /min (HI)
Oxygen Saturation: 90 %
Oxygen Delivery Method: Room air."


Hospital Admission Final Report

Chief Complaint
"RESPIRATORY DISTRESS
History of Present Illness
Patient is a 4-week-old F born at 39 weeks who presents for apnea and lethargy. Parents report 6 days of nasal congestion and cough.
Presented to DCMC ER 1/25 for those symptoms and was discharged home with dx of viral illness. At that time, she had 1 post tussive emesis. Patient continued to have congestion, cough, and some increased WOB on day 4 of illness parents
took patient to TCH ER. She was suctioned and discharged home with dx of viral illness. Within the last two days, patient with more episodes of posttussive emesis, decreased appetite and decreased wet diapers. She also became more tired and was sleeping more. On day of admission, parents took her to closest OSH near home. Due to her state of illness, they advised her to drive to the closest hospital. During route, patient became apneic and parents pulled over and called 911. Patient found to be apneic and cyanotic, was bagged by EMS. She was soon air flighted to DCMC and while Enroute had episodes of apnea and desaturations into 50s requiring bagging. No fever throughout illness. No rash, no diarrhea. Old sibling with cough and congestion prior to patient's. No COVID exposure. Parents not vaccinated for COVID.

Assessment/Plan
Diagnoses and Plan
1. Acute respiratory failure with hypercapnia
2. Apnea
3. Hypothermia
4. Acute hyponatremia
5. Lethargy
6. Viral respiratory illness
7. Hypoglycemia
8. Transaminitis
9. Hyperammonemia."

Patient #1" is a 4-week-old F born at 39 weeks who presents to PICU for acute respiratory failure with hypercapnia, apnea, and lethargy. Viral process with possible superimposed bacterial infection highest on ddx at this time, however, cannot exclude other etiologies. Hypercapnia possibly due to obstructive process. Intubated 1/29. Continued hospitalization for respiratory support and close cardiorespiratory monitoring."
- Fentanyl drip with matching bolus
- Precedex drip with matching bolus
Resp: acute respiratory failure with hypercapnia,
possibly obstructive process, s/p x1 methylpred
- SIMV: FiO2 50%, rate 30, PEEP 7, rate 22
- VBG q1h
- Continuous albuterol 10mg q1h
- Atrovent q6h
CV: tachycardia 2/2 albuterol; no cardiomegaly on XR, BNP
2853
- Repeat BNP in AM
- If worsening or persistent hypoxemia, consider ECHO
FEN/GI: hyponatremia (resolved), Hyperammonemia
(resolved); Transaminitis; s/p x 4 NS bolus
- US abdomen complete
- NG tube in place
- IVF: D10 1/2 NS + KCl at maintenance
Neuro: sedated; s/p vec x2
- Cranial US
- Fentanyl drip with matching bolus
- Precedex drip with matching bolus
Resp: acute respiratory failure with hypercapnia,
possibly obstructive process, s/p x1 methylpred
- SIMV: FiO2 50%, rate 30, PEEP 7, rate 22
- VBG q1h
- Continuous albuterol 10mg q1h
- Atrovent q6h
CV: tachycardic 2/2 albuterol; no cardiomegaly on XR, BNP
2853
- Repeat BNP in AM
- If worsening or persistent hypoxemia, consider ECHO
FEN/GI: hyponatremia (resolved), Hyperammonemia
(resolved); transaminitis; s/p x 4 NS bolus
- US abdomen complete
- NG tube in place
- IVF: D10 1/2 NS + KCl at maintenance"

Reviewed Physician's Emergency Room Documentation:
"Patient is a 4-week-old female born at term presented to the emergency department after being seen at an OSH immediately prior for congestion and poor feeding. The family were instructed by outside facility to drive the patient to the nearest pediatric hospital.

Patient developed apnea while the parents were transporting her to "#2 "Children's. 911 was called. EMS contacted airlift service. Patient was flown to the DCMC. Flight nurse reported patient had a bradycardia episode in flight that resolved with BVM. She received 100 ml of normal saline by the flight crew.

On arrival patient was dusky in color. Her room air sats were 86 to 88%. She had a rectal temp of 94.1. She had a right tibial IO in place. She was placed on a warmer. And peripheral IVs were obtained x 2. She was placed on nasal cannula at 2 L. With increase in sats to 100%. Her anterior fontanel was sunken. Her lips were dry. Her mucous membranes were dry. Her respiratory rate was slightly increased with no retractions noted, she had slight coarse breath sounds. Her cardiac exam was significant for tachycardia. No murmur or gallop was identified. Her abdomen was soft, and her liver edge was approximately 2 cm down. She had decreased tone in her lower extremities. She had a good suck.

A chest x-ray was obtained that demonstrated a right upper lobe infiltrate. CBC, CMP BNP RPP and cultures were obtained. VBG demonstrated respiratory acidosis with a PCO2 of 80 and a metabolic acidosis with a lactic acid of 5.5. The VBG also identified a sodium of 124 and a glucose of 51. Glucose was treated with D10.

Patient developed apnea requiring stimulation. Decision was made to intubate child. Patient was treated with ampicillin and ceftriaxone for pneumonia and sepsis. She was given succinylcholine and fentanyl for intubation. There were 3 unsuccessful attempts at intubation in the emergency department requiring anesthesia's presence. Anesthesia successfully intubated the patient.

Patient had continued intermittent desats when placed on the ventilator. Her sats would increase with manual bagging. Suctioning per RT demonstrated some thick white mucus. Her ET tube was right mainstem on chest x-ray. Tube was withdrawn 1 cm. During transport to the PICU she had a desaturation to 55% in the elevator. She was again taken off the ventilator with sats increasing with bag-valve-mask ventilation. Patient then transported to the pediatric ICU. Report was given to Dr. ------. Parents were updated throughout the course of the resuscitation. They were present at the bedside.

Respiratory failure acute with hypoxemia
Sepsis
RUL Pneumonia
Apnea
Metabolic Acidosis
Respiratory Acidosis
Hyponatremia
Hypoglycemia"


Reviewed A Report from the Facility's Medical Director regarding the incident.

Review of documentation from the Facility's Medical Director dated January 31, 2022 "RE ER incident - Baby seen in lobby "(Patient #1)":
"I was notified by ------, Director of Nursing and ------, RN ED Nurse Manager regarding an event occurring on January 29, 2022. They informed me of a mother bringing her baby into the Emergency room. The mother was greeted by a nurse in the lobby followed by the ED physician, "Physician (# 58)", also meeting the mother in the lobby. At that time didn't know much about the discussion that went on between the ED physician and mother. However, the mother left with the baby not been registered without a chart generated.
It was found out thru hearsay on the way to "#2 Children's Hospital" 911 had been called and a decision had been made to transfer the baby by air ambulance.

Without knowing further detail, I was able to reach Physician (#58) and inform him what happened after the mother had left the ER lobby. I explained to "Physician (#58)" that we do not see patients in the lobby and that all patients need to be brought back. He reported he felt mom really wanted a second opinion whether to go to "#2 Children's Hospital" or not and the baby was cooing. A second conversation with made with Physician (#58) and informed him the baby was intubated and in the ICU at "#2 Children's Hospital."


Reviewed Personnel and credentialing files for Physician (#58).
Review on 02/10/2022 of Physician (#58 ) personnel and credentialing record revealed he was granted privilege by the hospital and re-appointed to work as an emergency room staff on January 21, 2022 - January 30th, 2023.
Review of the record revealed no evidence that the Physician completed orientation to the facility. There was no document of a re-Inservice/ retraining given to physicians on EMTALA requirements since the incident with Patient #1.

Interview on 02/10/2022 at 9:00 a.m. with the Facility's Quality Assessment Performance Improvement Director revealed the physicians are contracted and the contract company is responsible for providing orientation to the physicians and a packet on orientation is given to the Physician.
The Quality Assessment Performance Improvement Director provide a packet from the contract company which was signed on 11/20/2017 by Physician (#58). This was not included in the Physician's records during review. This document was titled COBRA/EMTALA. The "20 Commandments" of COBRA/ EMTALA.

Reviewed Facility's Policy and Procedure
Review of the Facility's Policy and Procedure on Orientation New Employees, Policy # ALL 301, revised 10/21, direct staff as follows: "Orientation of New employee will take place prior to the performance of job duties when feasible but will occur no later than thirty days after employment. "

Review of the Facility's central emergency registration log revealed no documentation of the Patient's visit. There was no documentation of an emergency medical screen conducted on the Patient by the physician. There was no indication that re-in-service, or retraining was provided to the physician after the incident. This physician is a contracted staff and there was no documentation of facility's orientation of the Physician. Record provided by the facility's staff, revealed the most current in-service on EMTALA regulations, of the Physician was completed in 2017 by the contract company.

Interview with patients, numerous staff members and review of the facility's camera recording, it is determined, that the Patient was brought to the facility's emergency room on 01/29/2022 by her mother and another family member. On entering the facility's lobby with another family member and a baby wrapped in a blanket, they approached the registration desk, and the mother told the person at the registration desk that the baby was lethargic; she had taken the baby to two other hospitals where she was told by one of the hospital's personnel, that the baby had a viral infection.

A clipboard with papers were given to the patient's mother.
The Registered Nurse on duty notified the physician on duty of the patient's presence in the lobby. The Physician proceeded to lobby where the mother, family member and child were waiting. The Physician on duty said the mother told him "I need you to see my child."

Review of the camera recording (without audible sound) revealed a dialogue between the mother of the baby and the physician while in the lobby.

Interview with the patient's mother and the registered nurse who were present during the visit revealed, the Physician told the baby's mother to take the baby to a
pediatric hospital. The Physician denied given this instruction.

The family left the facility after the alleged instruction at 15:29 p.m. On their way to #2 Children's Hospital, the Mother became concern about the baby's safety and placed a call to her pediatrician, who directed her to pull over and call 911. EMT was dispatched at approximately 16:00 p.m. The Patient was transferred to La Grange via ground ambulance. The baby required manual bagging to improve respiration during travel to La Grange. She was then air lifted to #2 Children's Hospital (arrival time 17:14 p.m.) where subsequently the child was intubated and placed on a ventilator.

The record revealed a Medical Screening Exam (MSE) was not conducted on Patient #1 by the emergency room physician when the patient was taken to the facility's emergency room by family.