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Based on document review, medical record review and interview, the facility failed to ensure compliance with the Condition of Participation of Emergency Services. Specifically, the facility failed to address Patient #1's presenting symptoms of 10/10 headache, screaming in pain, slurred speech, and altered mental status. This could lead to a patient not being provided with appropriate treatment.

Findings include:

-- Hospital staff failed to monitor a patient (Patient #1) who presented to the emergency department with a 10/10 headache, screaming in pain, slurred speech and altered mental status. See Tag A1104.

Based on document review, medical record review, and interview, in 1 of 20 medical records reviewed, the hospital failed to provide appropriate care to Patient #1. Specifically, the facility failed to address Patient #1's presenting symptoms of 10/10 headache, screaming in pain, slurred speech, and altered mental status. This could lead to a patient not being provided with appropriate treatment.

Findings include:

-- Per review of facility's policy and procedure (P&P) titled, EMTALA - Screening, Stabilization, Management of Transfers and Recordkeeping; Reporting Suspected EMTALA Violations, last revised 1/3/2023, "A Medical Screening Examination is an ongoing process, not an isolated event. As screening and treatment progress the record must reflect continued monitoring according to the individual's needs and must continue until it is determined that the individual does not have an Emergency Medical Condition or is Stabilized or Appropriately Transferred. ... Scope of Examination - A Medical Screening Examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an Emergency Medical Condition exists or not. The scope of the examination must be tailored to the presenting complaint, signs and symptoms, and the medical history of the individual. The process may range from a simple examination (such as a brief history and physical) to a complex examination that may include laboratory tests, MRI or diagnostic imaging, lumbar punctures, other diagnostic tests and procedures, information from other sources (e.g. pre-hospital care providers, law enforcement, family or friends as applicable), and the use of on-call Physician specialists. A medical record documenting the history and physical examination, and any special reports such as consultations, clinical laboratory, x-ray, etc., will be created to document the Medical Screening Examination. ... A Medical Screening Examination is an ongoing process, not an isolated event. As screening and treatment progress, the record will reflect continued monitoring according to the individual's needs and continue until it is determined that the person does not have an Emergency Medical Condition or the person is Stabilized or Appropriately Transferred."

-- Per review of facility's policy and procedure (P&P) titled, "Emergency Department Triage Policy," last revised 2/26/2024, ESI Level 2 is a condition that has the potential to threaten life and limb and requires rapid medical interventions."

-- Per medical record review, Patient #1, presented to emergency department on 3/21/2024 at 10:51 am.

Patient #1 triaged as a level 2 on Emergency Severity Index (1 is critical - 5 least urgent) at 11:13 am.

At 11:20 am, Patient #1 seen by provider. Note stated "Patient is a [age and gender] with no significant PMH (past medical history) who was brought to emergency department from school due to not being themselves at school. This morning, school called mom and when she went to pick up, he was weak and on wheelchair. Patient reports having 10/10 headache, over forehead, associated with right ear pain, nausea and vomiting. Was recently diagnosed with streptococcal pharyngitis (strep throat) and is currently treated with amoxicillin at home. Today is day 7 of amoxicillin. Denies fever, chills, skin rash, chest pain, shortness of breath, abdominal pain." Review of systems revealed Patient #1 positive for nausea and vomiting and headaches. Physical exam revealed Patient #1 was in acute distress, screaming in pain, and vomiting at the bedside. Right ear tympanic membrane is erythematous (red). Point of care testing glucose fingerstick showed 297 (normal 70-110. Hyperglycemia is elevated glucose level). Complete blood count, complete metabolic panel, urine analysis, and urine toxicology pending. Chest x-ray also ordered.

Medical decision making included Patient #1 vomited twice at the bedside.

Differential diagnosis at this time included but not limited to diabetic ketoacidosis (a serious complication of diabetes. signs and symptoms include thirst, frequent urination, feeling a need to throw up and throwing up, stomach pain. weakness, tiredness, shortness of breath, confusion), substance use, acute otitis media, and meningococcal infection. (Meningitis is a serious infection and inflammation of the fluid and membranes surrounding the brain and spinal cord. The inflammation from meningitis typically triggers symptoms such as headache, fever, and a stiff neck.)

Complete metabolic panel resulted at 12:43 pm indicated glucose level was 274.

Patient #1's neurological exam at 1:00 pm revealed Patient #1's speech was garbled.

Tylenol (pain medication) was administered at 1:48 pm, (3 hours after presented with 10/10 headache).

At 3:02 pm Patient #1's first temperature (98.5 degrees Fahrenheit) was obtained by staff (more than 4 hours after presenting to the hospital). No further temperatures were documented.

Urine resulted at 4:46 pm showed urine glucose 4+ (abnormal), urine protein 1+ (abnormal), urine ketones 1+ (abnormal). Urine toxicology screen results were all negative. At 6:42 pm patient's transfer disposition set - to transfer to another hospital.

At 7:11 pm a pediatric attending consultant assessed the child. The pediatrician's assessment and plan stated "... based on clinical findings and laboratory results, is unclear what is the etiology of presentation. Patient will benefit for transfer to higher level of care facility for further evaluation and management.

At 11:37 pm, Patient #1 was transferred to another hospital via ambulance. Condition was stable. Vital signs were heart rate - 89, respirations - 20, blood pressure - 118/81, and oxygen saturation: 99 %. Denied pain.

-- Per interview of Staff A, Physician on 5/24/2024 at 11:50 am, he/she/they recalled the patient was just screaming. His mother stated he was "normal" prior to this event. There were a number differential diagnoses, including substance abuse and diabetic ketoacidosis which can present with altered mental status.

-- Per interview of Staff B, Physician, on 5/24/2024 at 12:05 pm, he/she/they said diabetic ketoacidosis can cause altered mental status. Staff B was concerned about possible substance induced problem. Patient had a recent strep infection, so possibly an infectious process. He had no signs of head trauma, he had not fallen or been in a fight, so a head computed tomography was not indicated at the time.

-- During interview of Staff C, Manager of Quality Management on 5/24/2024 at 3:00 pm, he/she/they acknowledged these findings.