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Based on review of facility documents, review of clinical records, and staff interview, the facility failed to provide, within the capabilities of the staff and facilities available at the hospital, appropriate medical treatment as required to stabilize the medical condition of the patient or transfer to another medical facility. The hospital policy correctly defined "Stabilize - means, with respect to an Emergency Medical Condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur ..." Patient #13 had grossly abnormal vital signs that were not addressed prior to discharge. The patient had an emergency medical condition (EMC), presented to the ED with flu like symptoms.


Findings:

"Standards of Nursing Practice" set forth by the Texas Boar of Nursing stated in part, "The standards of practice establish a minimum acceptable level of nursing practice in any setting ... Failure to meet these standards may result in action against the nurse's license ...

(1) Standards Applicable to All Nurses ...

...(B) Implement measures to promote a safe environment for clients and others ...

(D) Accurately and completely report and document:

(i) the client's status including signs and symptoms

...(v) client response(s)

...(M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications;

...(P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care.

...(3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall:

(A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by:

(i) performing comprehensive nursing assessments regarding the health status of the client;

...(v) evaluating the client's responses to nursing interventions."



Facility-used reference titled "Skills: Emergency Secondary Assessment (Pediatric)" stated in part, "Normal Heart Rates [HR] ... School-age Child (6-7 yr): Awake heart rate (bpm, beats per minute) 75-118; Sleeping heart rate (bpm): 58-90 ..."


Facility-based policy titled "Patient Transfer (EMTALA)" stated in part, "Definitions:

Emergency Medical Condition - means a medical condition manifesting itself by acute symptoms of sufficient severity ... such that the absence of immediate medical attention could reasonable be expected to result in:

1. Placing the health of the individual ... in serious injury;

2. Serious impairment to any bodily functions;

3. Serious dysfunction of any bodily organ or part ...

Stabilize - means, with respect to an Emergency Medical Condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur ..."

Policy:

...Patient Rights: BSWH recognizes the right of an individual to receive, within the capabilities of the medical center's staff and facilities:

*An appropriate medical screening examination;

*Necessary stabilizing treatment ...

Procedure:

Patient Evaluation:

...Emergency Medical Condition: If an Emergency Medical Condition exists, the medical center must provide, within the capabilities of the medical center, any necessary stabilizing treatment, an appropriate Transfer or admit the Patient for further treatment."



Patient #13, a 6-year-old, arrived to the emergency department [ED] of this hospital on 1/4/19 at 2:24 am with a chief complaint of fever and cough. Patient #13 was triaged at 2:27 am with a negative pediatric sepsis screen and no infection control issues. Vital signs at 2:28 am revealed an oral temperature of 98.3° F, a heart rate of 165 bpm, respiratory rate [RR] of 24, oxygen saturation [measure of oxygen levels in the blood] of 100% on room air and a pain assessment of "hurts even more" that was generalized.

At 3:52 am, patient #13 was taken to an ED room and assigned a nurse and physician.

ED nursing note dated 1/4/19 at 3:57 am stated in part, "Per dad pt [patient] was diagnosed with the flu Tuesday night and now pt is unable to sleep due to pain ..." The nurse charted patient #13's respiratory was within defined limits at 4:00 am. Orders were placed at 4:02 am for chest x-ray, ibuprofen and Tylenol by mouth.

Nursing note dated 1/4/19 at 4:10 am stated in part, "Pt vomited X 1 before nurse entered room, dad states this is pt's third time vomiting." Patient #13 was given Zofran disintegrating tablet [for nausea] at 4:30 am and HR was rechecked and read 166.

Nursing note dated 1/4/19 at 4:31 am stated in part, "Pt vomiting again, prior to Zofran administration. Dad was giving pt water, nurse instructed dad to not give pt anything to drink at this time. Dad verbalized understanding."

X-ray was completed at 4:30 am and resulted at 4:38 am as "normal chest for age." Glucose was checked at 5:17 am, slightly elevated at 139.


ED provider record dated 1/4/19 at 5:19 am stated in part, " ...[Patient #13] was seen at Urgent care 2 days ago and found to test positive for influenza. They were counseled about supportive care. Mother states that since [patient #13] has had body aches and [they have] had trouble sleeping. [They have] also had persistent cough ...

Review of Systems: Constitutional: Positive for fever.

HENT [head, ears, nose, throat]: Positive for congestion and rhinorrhea [mucus in nasal cavity].

...Respiratory: Positive for cough

...Gastrointestinal: Positive for vomiting.

Endocrine: Positive for polydipsia [excessive thirst].

...Musculoskeletal: Positive for arthralgias [joint pain] and myalgias [muscle pain].

...Psychiatric/Behavioral: Positive for sleep disturbance.

...Physical Exam:

Constitutional: [They appear] well-nourished. No distress.

...Nose: Nasal discharge present.

Mouth/Throat: Mucous membranes are moist.

...Cardiovascular: Regular rhythm. Tachycardia present.

Pulmonary/Chest: Effort normal. [Patient #13] has rhonchi [rattling, coarse breath sounds].

Occasional rhonchi that clear with cough. No respiratory distress.

...Neurological: [They are] alert.

Skin: Skin is warm. Capillary refill takes less than 3 seconds. No rash noted.

...MDM [Medical Decision Making]

Viral illness: Diagnosis management comments:

Patient is a 6 year old with symptoms consistent with influenza like illness. [They are] not in respiratory distress and is non-toxic appearing. Obtained chest radiograph and no visible infiltrate to suggest pneumonia. [Patient #13] had some post-tussive emesis here. Blood glucose checked to ensure [they were] not having new onset diabetes with ketoacidosis, and glucose was 139. Again counseled parents on supportive care, recommended children's Delsym for cough and diphenhydramine for congestion and sleep. Discharged home.

...Patient Progress: stable
Final diagnoses: Viral illness ..."


Patient #13 was given ibuprofen orally at 5:19 am and Tylenol at 5:20 am. They were discharged at 5:49 am. There was no evidence temperature or heart rate was rechecked. There was no blood pressure taken during patient #13's time at the ED.



Patient #13 was brought to hospital #2 on 1/4/19 at 8:13 am with a medical record that stated in part, "Mode of arrival: The patient arrived by walk in and by being carried ... Initial vitals at presentation: 1/4/19 8:15 am. ASSESMENT: HR 181 Sitting Awake, RR: 61, Pain: 8/10, Note: unable to obtain BP/has palpable brachial pulse, unable to obtain O2 [oxygen saturation].
...Patient Safety Screening: ...Developmental screening: Notes: unable to assess d/t [due to] altered mental status ...

General Assessment:

Constitutional: The patient was in severe distress.

Speech: No speech is present. Grnuting [sic] and moaning on arrival, per parent pt has been awake x2 days and has been grunting/moaning all night ...

Skin: The skin was cool and dry. Skin color was mottled [blotchy skin color indicating abnormality of blood circulation]. Skin turgor was decreased [indication of dehydration] ...


Patient #13's course while at hospital #2 was difficult. Patient #13 was given IV [intravenous] fluids, urine, and laboratory studies were completed; EKG and chest x-rays were obtained Glucose and bicarbonate were administered. Transferred to PICU [pediatric intensive care unit]. Patient #13 lost pulse a total of four times. Approximately 10:00 am, on 1/4/19, the transport team arrived and helped with the final resuscitation efforts, but patient #13 passed with final expiration impressions of severe sepsis with septic shock and influenza type A.


In an interview with staff #20, ED RN for hospital #1, on the afternoon of 2/26/19, when asked what they would do if a physician wanted to discharge a 6-year-old patient with a HR of 166, staff #20 stated, "I would go back to the physician." When asked if they would discharge that patient, they stated, "No."


In an interview with staff #21, ED RN for hospital #1, on the afternoon of 2/26/19, when asked what they would do if a physician wanted to discharge a 6-year-old patient with a HR of 166, they stated, "I don't think that's safe. I would advocate for my patient." When asked if they would let that patient go home, they stated, "No way."


In an interview with staff #7, ED doctor for hospital #1, on the evening of 2/26/19, when asked about patient #13's charted heart rate at 165 and 166, staff #7 stated, "It's not uncommon [a heart rate of 166] if they have respiratory issues." When asked if it was rechecked, they stated, "Yeah, [patient #13] was on a continuous pulse ox. When I came back in the room, [patient #13] was still on pulse ox, so it ranged from 130s to high 160s, that was really the only vital that was abnormal, which happens in the cases when the children are febrile, have a fever. [Patient #13] was very anxious; [they] didn't like to be touched ... [they weren't] in pain but was very scared to be there ..." When asked why other children with nausea/vomiting were ordered PO [oral] challenges and not patient #13, they stated, "[Patient #13] did get some juice and [they] held it down, but [they] had what's called post-tussis, so when [they were] coughing [it would cause vomiting]. Mucous membranes were moist, good perfusion. When a child has GI [gastrointestinal] issues, anti-emetics and PO challenge is a reasonable course, if they would be able to tolerate [PO]. [This] case, [their] vomiting was what preceded by coughing. Controlling the cough could control the symptoms, so that would be the best way. [Their] mom backed that up [coughing preceded vomiting]."


In an interview with staff #19, ED RN for hospital #1, when asked what they would do when a child has tachycardia, staff #19 stated, "Depends on the entire thing, with [patient #13] I remember seeing, like when I saw [their] last heart rate it was tachy. I know [they were] recently diagnosed with flu and [they] had pain, every time we went in there it would go up. I thought all those things helped that [increased heart rate]." When asked if they remember the heart rate, staff #19 stated, "130s and whenever we messed with [patient #13] 160s." When asked what a normal heart rate was, they stated, "For [their] age, 50s to 115s is normal for a 6-year-old." When asked to verify the last charted heart rate was 166, staff #19 stated, "I believe so." When asked what patient #13's heart rate was while they were [patient #13's] nurse, staff #19 stated, "From what I've seen is 130s - 160s." When asked if they felt comfortable with the discharged with that HR range, staff #19 stated, "I did. I charted 160s while I was in the room and it only went up when we were in the room and attempting to do things with [patient #13]."


Patient #13 arrived to hospital #1 and vomited several times while there. A chest X-ray and glucose level were obtained; medications were given for pain, temperature and nausea. Patient #13 was discharged without documentation heart rate decreased or a recheck of vital signs. Two hours and 24 minutes after discharge, patient #13 arrived in critical condition to hospital #2 and ultimately passed.