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Based on document review and staff interviews, Hospital A's administrative staff failed to ensure Hospital A's Emergency Department staff provided 1 of 20 emergency patients reviewed (Patient #5) with an appropriate medical screening examination (MSE) after presenting to the Emergency Department (ED) with their parent(s) seeking medical care. Failure to provide an appropriate MSE at Hospital A's ED resulted in Patient #5 not receiving appropriate care, and subsequently being taken to Hospital B's ED by ambulance following a seizure. Hospital A's administrative staff identified an average of 278 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy "Emergency Medical Treatment and Labor Act (EMTALA)," Last modified on 7/13/2015, revealed in part, " ... Any patient who presents to the hospital seeking examination or treatment shall be offered a medical screening examination to determine whether an emergency medical condition exists, and shall not be transferred from the hospital until this exam has been completed... if you have a medical emergency ..., you have the right to receive, within the capabilities of this hospital's staff and facilities: An appropriate Medical Screening Examination and necessary stabilizing treatment."

2. Review of Patient # 5's medical record from Hospital A revealed:

a. On 12/19/22 at 7:06 PM, Patient #5 presented to Hospital A's ED by car, accompanied by their mother for concerns of seizure-like activity.

b. On 12/19/22 t 7:11 PM, EMT E triaged Patient #5 and documented they presents to ED ambulatory, and Patient #5's mother reported they had been prescribed Aripiprazole (antipsychotic medication used to treat mental health) 5 mg and Quetiapine Fumarate (antipsychotic medication used to treat certain mental/mood conditions) 25 mg 3 days prior. Since starting the medication Patient #5's mother reported they were sleeping excessively and having episodes of shaking, and believed they may be having a seizure.

c. On 12/19/22 at 7:22 PM, RN B noted Patient #5's mother stated Patient #5 had been drooling a lot and their jaw would clench up and quiver. Denied Patient #5 having any loss of consciousness. Patient #5 was alert and awake, but appeared dazed.

d. On 12/19/22 at 7:22 PM, RN B noted Patient #5 was alert and oriented to self, place, time, and situation, they were able follow commands with appropriate attention and concentration, their speech was clear, pupils were equal, their neurological symptoms were drowsy, and they had no seizure-like activity.

e. On 12/19/22 at 7:45 PM, MD F was at Patient # 5's bedside. MD F noted in his progress note that Patient #5's chief complaint was a medication reaction. Patient #5's physical exam by MD F noted their appearance as well-developed and not toxic-appearing, pupils were equal, round, and reactive to light, and neurological assessment showed no focal deficit present. MD F noted that Patient #5 was easily aroused and had no motor weakness. MD F also noted having a discussion with Patient #5's mother about tardive dyskinesia (a condition affecting the nervous system, often caused by long-term use of some psychiatric drugs, which causes repetitive, involuntary movements, such as grimacing and eye blinking) as the likely cause of Patient #5's "seizure like activity," finding more activities for Patient # 5 to engage in, and keeping them off of antipsychotic medications. Patient #5 was diagnosed with tardive dyskinesia. MD F failed to order any labs or imaging to evaluate or rule out the possibility of seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone and movements, behaviors, sensations, or state of awareness).

f. On 12/19/22 at 8:02 PM, RN B documented Patient #5's temperature as 96.7 (normal range is 97 - 99) degrees Fahrenheit. No other vital signs (body temperature, pulse rate, rate of breathing, and blood pressure) were documented on Patient #5.

g. On 12/19/22 at 8:23 PM, Patient #5 left AMA with his mother.

3. During an interview on 3/29/2023 at 1:30 PM, Medical Director A reported that Hospital A has a new device available to ED providers, called a Ceribell (a device used to read EEG waves for point-of-care seizure triage and treatment optimization). Medical Director A reported Hospital A received the Ceribell Device sometime in the fall, and would use this device to assess a patient for seizure activity, unless there were no active signs of a seizure, because the device would not do any good. Medical Director A also reported if a child was brought into the ED for reported seizure-like activity, they would observe the child, and possibly refer them to a neurologist. ED Provider A reported his course of care would depend on the patients presenting symptoms, and the story provided to them by the parents, because sometimes what the parents think may be a seizure, the symptoms they describe doesn't match for seizure activity. Medical Director A reported that ED Provider F might not have been aware of Hospital A's Ceribell device, as he is hardly ever at Hospital A.

4. During an interview on 3/29/2023 at 4:00 PM, MD F reported that if a patient comes to the ED for possible seizure activity he would first determine if the patient is having seizure activity, because he would not treat a patient if they were not having seizure activity. MD F reported they did not think Patient #5 was having seizure activity, and that it was muscle twitching. MD F explained that Patient #5 was able to speak to MD F, and they were just lying there the whole time they were in the ED. MD F reported speaking to Patient #5's mother, and they reported Patient #5 was recently placed on a very high dose of medication, an adult dose. MD F reported reviewing Patient #5's diagnosis and medication with Patient #5's mother, and that Patient #5 was taking several medications. MD F recalled questioning Patient #5's mother about Patient #5's behaviors, and asking her about their dad and his involvement with Patient #5. Patient #5's mother reported to MD F that she didn't want Patient #5's dad around. MD F reported their discussion with Patient #5's mother, and that they explained the behaviors Patient #5 was having, could have been related to dad's lack of involvement. MD F reported that Patient #5's mother was not happy when they told them the medication was harming Patient #5 MD F stated that Patient #5's mother "was very angry when [MD F] told [Patient #5's mom] and [Patient #5's dad] need to be more involved with [Patient #5]." ED Provider F reported seeing a child that was "snowed, when [MD F] say that, I mean sedated," had multiple diagnoses, was taking adult doses of psychiatric medication (medications taken to affect the chemical makeup of the brain and nervous system to treat mental health), and there were "clearly issues between [Patient #5's mom] and [Patient #5's dad]." ED Provider F explained he was very concerned about Patient #5, and that they communicated that to Patient #5's mother. ED Provider F also explained that they discussed with Patient #5's mother, that Patient #5's mom and Patient #5's dad needed to love Patient #5.

5. During an interview on 3/27/2023 at 1:25 PM, Patient #5's parent recalled bringing Patient #5 to Hospital A's ED, when they arrived at Hospital A's ED Patient #5 was kind of responsive, but out of it, and by the time the provider entered the room Patient #5 was "out of it, passing out, and couldn't stay awake." Patient #5's parent reported that when the provider came into the room he asked them "what is wrong with you?" Patient #5's parent began to explain the reason for bringing Patient #5 to the ED, but the provider again asked Patient #5's parent "what is wrong with you?" Patient #5's parent recalls the provider telling her "[Patient #5's parent] my age are not able to control kids, so they drug them," and told them "I was over drugging my kid." Patient #5's parent tried to explain to the provider Patient #5's medical history including their aggression and behaviors, diagnoses, and medications. Patient #5's parent explained Patient #5 has seen several different providers, that they brought Patient #5 to Hospital A's ED seeking help, and recalled the provider told them they were over doctoring their child, and this is what happens when you overdose your child. Patient #5's parent also recalled the provider telling them Patient #5 did not have any of the diagnoses and started crossing medications off the list, stating, "this is what is wrong with [Patient #5], and this is what is wrong with [Patient #5]." Patient #5's parent reported the provider told them they did not know how to parent a boy, and questioned them about the other parent, telling them they should be home more, and to be a stronger person. Patient #5's parent then reported the provider "turned to [Patient #5] and said your [parent] is trying to be a good [parent], [they] just need to be stronger, and not give you all that medication, right?" Patient #5's parent then recalled the provider throwing their badge in the parents face and saying "what does that say, I am the real doctor." Finally, Patient #5's parent reported that when the provider left the room to get paper work for them on overdosing, they left Hospital A's ED with Patient #5 due to the treatment they received by the provider, and when they walked out of the exam room nobody was around, so they just left.

6. During observation of Hospital A's ED on 3/27/23 at 10:35 AM, it was noted the ED had a total of six rooms, three entrances, and is staffed with one RN, one physician, one paramedic, and one tech/EMT at all times. The paramedic and tech/EMT assist in the ED when not out on an ambulance call. The first entrance is off the main hallway of the hospital, and has a small waiting area and a nurse's station, but staff are not always present in this area. From the waiting area patients enter into a hallway of the ED with 4 ED exam rooms, at the end of this hall is another door entering a second hallway with two trauma bays, and the second entrance from a garage where patients can pull their vehicle into and enter the ED. In the second hallway, there is a window where the ED tech sits, when not on an ambulance call, and will greet patients upon arrival from the garage entrance. At the end of this second hallway there is a third entrance door into the hallway of the hospital, this door is badge access only to enter, but anyone can exit.

7. During an interview on 3/29/2023 at 12:00 PM, Primary care provider (PCP) H reported Patient #5 was being seen by behavioral health in their clinic when they witness Patient #5's seizure activity. PCP H was called to assess Patient #5 during the seizure and called an ambulance for them to be transported to Hospital B's ED. PCP H reported they have seen Patient #5 since the hospitalization when Patient #5 was newly diagnosed with seizures and they have been hospitalized several more times. PCP H also reported Patient #5 has been a patient with their clinic for some time, and is seen by behavioral health every month.

8. Review of Patient # 5's medical record from Hospital B revealed:

a. On 12/20/22 at 11:38 AM, Patient #5 arrived at Hospital B by ambulance (15 hours after leaving Hospital A) for a witnessed a Grand Mal seizure (type of seizure that involves a loss of consciousness and violent muscle contractions). Upon arrival to Hospital B's ED Patient #5 was described as drooling, with a protruding tongue, and arm stiffness.

b. On 12/20/22 at 11:57 AM, DO G completed an assessment of Patient #5 and noted they were positive for seizures. Hospital B provided Patient #5 with further examination and treatment to stabilize his emergency medical condition.

9. During an interview on 4/1/23 at 10:54 AM, ARNP I reported seeing Patient #5 for the first time the day after they were admitted to Hospital B. Patient #5 was having seizure activity in Hospital B's ED, their symptoms were discussed with a neurologist from a pediatric hospital, and they were started on Keppra. ARNP I reported according to Patient #5's chart they had recently been started on Abilify, Clonidine (a sedative that can be used to control symptoms of attention deficit hyperactivity disorder), and Quetiapine Fumarate (antipsychotic medication used to treat certain mental/mood conditions), and it was thought these medications could have contributed to their symptoms. ARNP I reported that Hospital B's physicians felt Patient #5's symptoms could have been Tardive Dyskinesia symptoms from these medications being started all at once, so these medications were discontinued during Patient #5's ED visit at Hospital B, and they were given Benadryl (antihistamine that reduces the effects of allergies). ARNP I reported after treatment was initiated, Patient #5 did not demonstrate any seizure activity during his overnight observation at Hospital B, had returned to his baseline condition, and was eating and drinking, so Patient #5 was discharged. Patient #5 had to be readmitted to Hospital B that same day due to continued seizure-like activity. The neurologist was consulted again, and the Keppra was discontinued, and 2 other medications were started for seizures. It was confirmed during Patient #5's hospitalization at Hospital B that they were having seizures according to the EEG results.

Hospital A failed to provide Patient #5 with an appropriate MSE sufficient to determine whether or not an emergency medical condition existed. Patient #5's MSE lacked the necessary laboratory analyses and advanced imaging to confirm whether or not Patient #5's diagnosis of tardive dyskinesia was the definitive diagnosis and not another pathologic process. Patient #5 went on to suffer progressive decline of their condition with multiple episodes of seizures and presented to another hospital for an appropriate MSC and stabilizing treatment which were indicated.

Based on document review and staff interviews, Hospital A's administrative staff failed to ensure Hospital A's Emergency Department staff provided 1 of 20 emergency patients reviewed (Patient #5) with an appropriate medical screening examination (MSE) after presenting to the Emergency Department (ED) with their parent(s) seeking medical care. Failure to provide an appropriate MSE at Hospital A's ED resulted in Patient #5 not receiving appropriate care, and subsequently being taken to Hospital B's ED by ambulance following a seizure. Hospital A's administrative staff identified an average of 278 patients per month who presented to the dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient # 5's medical record from Hospital A revealed:

a. On 12/19/22 at 7:06 PM, Patient #5 presented to Hospital A's ED by car, accompanied by their mother for concerns of seizure-like activity.

b. On 12/19/22 t 7:11 PM, EMT E triaged Patient #5 and documented they presents to ED ambulatory, and Patient #5's mother reported they had been prescribed Aripiprazole (antipsychotic medication used to treat mental health) 5 mg and Quetiapine Fumarate (antipsychotic medication used to treat certain mental/mood conditions) 25 mg 3 days prior. Since starting the medication Patient #5's mother reported they were sleeping excessively and having episodes of shaking, and believed they may be having a seizure.

c. On 12/19/22 at 7:22 PM, RN B noted Patient #5's mother stated Patient #5 had been drooling a lot and their jaw would clench up and quiver. Denied Patient #5 having any loss of consciousness. Patient #5 was alert and awake, but appeared dazed.

d. On 12/19/22 at 7:22 PM, RN B noted Patient #5 was alert and oriented to self, place, time, and situation, they were able follow commands with appropriate attention and concentration, their speech was clear, pupils were equal, their neurological symptoms were drowsy, and they had no seizure-like activity.

e. On 12/19/22 at 7:45 PM, MD F was at Patient # 5's bedside. MD F noted in his progress note that Patient #5's chief complaint was a medication reaction. Patient #5's physical exam by MD F noted their appearance as well-developed and not toxic-appearing, pupils were equal, round, and reactive to light, and neurological assessment showed no focal deficit present. MD F noted that Patient #5 was easily aroused and had no motor weakness. MD F also noted having a discussion with Patient #5's mother about tardive dyskinesia (a condition affecting the nervous system, often caused by long-term use of some psychiatric drugs, which causes repetitive, involuntary movements, such as grimacing and eye blinking) as the likely cause of Patient #5's "seizure like activity," finding more activities for Patient # 5 to engage in, and keeping them off of antipsychotic medications. Patient #5 was diagnosed with tardive dyskinesia. MD F failed to order any labs or imaging to evaluate or rule out the possibility of seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone and movements, behaviors, sensations, or state of awareness).

f. On 12/19/22 at 8:02 PM, RN B documented Patient #5's temperature as 96.7 (normal range is 97 - 99) degrees Fahrenheit. No other vital signs (body temperature, pulse rate, rate of breathing, and blood pressure) were documented on Patient # 5.

g. On 12/19/22 at 8:23 PM, Patient #5 left AMA with his mother.

2. During an interview on 3/29/2023 at 1:30 PM, Medical Director A reported that Hospital A has a new device available to ED providers, called a Ceribell (a device used to read EEG waves for point-of-care seizure triage and treatment optimization). Medical Director A reported Hospital A received the Ceribell Device sometime in the fall, and would use this device to assess a patient for seizure activity, unless there were no active signs of a seizure, because the device would not do any good. Medical Director A also reported if a child was brought into the ED for reported seizure-like activity, they would observe the child, and possibly refer them to a neurologist. ED Provider A reported his course of care would depend on the patients presenting symptoms, and the story provided to them by the parents, because sometimes what the parents think may be a seizure, the symptoms they describe doesn't match for seizure activity. Medical Director A reported that ED Provider F might not have been aware of Hospital A's Ceribell device, as he is hardly ever at Hospital A.

3. During an interview on 3/29/2023 at 4:00 PM, MD F reported that if a patient comes to the ED for possible seizure activity he would first determine if the patient is having seizure activity, because he would not treat a patient if they were not having seizure activity. MD F reported they did not think Patient #5 was having seizure activity, and that it was muscle twitching. MD F explained that Patient #5 was able to speak to MD F, and they were just lying there the whole time they were in the ED. MD F reported speaking to Patient #5's mother, and they reported Patient #5 was recently placed on a very high dose of medication, an adult dose. MD F reported reviewing Patient #5's diagnosis and medication with Patient #5's mother, and that Patient #5 was taking several medications. MD F recalled questioning Patient #5's mother about Patient #5's behaviors, and asking her about their dad and his involvement with Patient #5. Patient #5's mother reported to MD F that she didn't want Patient #5's dad around. MD F reported their discussion with Patient #5's mother, and that they explained the behaviors Patient #5 was having, could have been related to dad's lack of involvement. MD F reported that Patient #5's mother was not happy when they told them the medication was harming Patient #5 MD F stated that Patient #5's mother "was very angry when [MD F] told [Patient #5's mom] and [Patient #5's dad] need to be more involved with [Patient #5]." ED Provider F reported seeing a child that was "snowed, when [MD F] say that, I mean sedated," had multiple diagnoses, was taking adult doses of psychiatric medication (medications taken to affect the chemical makeup of the brain and nervous system to treat mental health), and there were "clearly issues between [Patient #5's mom] and [Patient #5's dad]." ED Provider F explained he was very concerned about Patient #5, and that they communicated that to Patient #5's mother. ED Provider F also explained that they discussed with Patient #5's mother, that Patient #5's mom and Patient #5's dad needed to love Patient #5.

4. During an interview on 3/27/2023 at 1:25 PM, Patient #5's parent recalled bringing Patient #5 to Hospital A's ED, when they arrived at Hospital A's ED Patient #5 was kind of responsive, but out of it, and by the time the provider entered the room Patient #5 was "out of it, passing out, and couldn't stay awake." Patient #5's parent reported that when the provider came into the room he asked them "what is wrong with you?" Patient #5's parent began to explain the reason for bringing Patient #5 to the ED, but the provider again asked Patient #5's parent "what is wrong with you?" Patient #5's parent recalls the provider telling her "[Patient #5's parent] my age are not able to control kids, so they drug them," and told them "I was over drugging my kid." Patient #5's parent tried to explain to the provider Patient #5's medical history including their aggression and behaviors, diagnoses, and medications. Patient #5's parent explained Patient #5 has seen several different providers, that they brought Patient #5 to Hospital A's ED seeking help, and recalled the provider told them they were over doctoring their child, and this is what happens when you overdose your child. Patient #5's parent also recalled the provider telling them Patient #5 did not have any of the diagnoses and started crossing medications off the list, stating, "this is what is wrong with [Patient #5], and this is what is wrong with [Patient #5]." Patient #5's parent reported the provider told them they did not know how to parent a boy, and questioned them about the other parent, telling them they should be home more, and to be a stronger person. Patient #5's parent then reported the provider "turned to [Patient #5] and said your [parent] is trying to be a good [parent], [they] just need to be stronger, and not give you all that medication, right?" Patient #5's parent then recalled the provider throwing their badge in the parents face and saying "what does that say, I am the real doctor." Finally, Patient #5's parent reported that when the provider left the room to get paper work for them on overdosing, they left Hospital A's ED with Patient #5 due to the treatment they received by the provider, and when they walked out of the exam room nobody was around, so they just left.

5. During observation of Hospital A's ED on 3/27/23 at 10:35 AM, it was noted the ED had a total of six rooms, three entrances, and is staffed with one RN, one physician, one paramedic, and one tech/EMT at all times. The paramedic and tech/EMT assist in the ED when not out on an ambulance call. The first entrance is off the main hallway of the hospital, and has a small waiting area and a nurse's station, but staff are not always present in this area. From the waiting area patients enter into a hallway of the ED with 4 ED exam rooms, at the end of this hall is another door entering a second hallway with two trauma bays, and the second entrance from a garage where patients can pull their vehicle into and enter the ED. In the second hallway, there is a window where the ED tech sits, when not on an ambulance call, and will greet patients upon arrival from the garage entrance. At the end of this second hallway there is a third entrance door into the hallway of the hospital, this door is badge access only to enter, but anyone can exit.

6. During an interview on 3/29/2023 at 12:00 PM, Primary care provider (PCP) H reported Patient #5 was being seen by behavioral health in their clinic when they witness Patient #5's seizure activity. PCP H was called to assess Patient #5 during the seizure and called an ambulance for them to be transported to Hospital B's ED. PCP H reported they have seen Patient #5 since the hospitalization when Patient #5 was newly diagnosed with seizures and they have been hospitalized several more times. PCP H also reported Patient #5 has been a patient with their clinic for some time, and is seen by behavioral health every month.

7. Review of Patient # 5's medical record from Hospital B revealed:

a. On 12/20/22 at 11:38 AM, Patient #5 arrived at Hospital B by ambulance (15 hours after leaving Hospital A) for a witnessed a Grand Mal seizure (type of seizure that involves a loss of consciousness and violent muscle contractions). Upon arrival to Hospital B's ED Patient #5 was described as drooling, with a protruding tongue, and arm stiffness.

b. On 12/20/22 at 11:57 AM, DO G completed an assessment of Patient #5 and noted they were positive for seizures. Hospital B provided Patient #5 with further examination and treatment to stabilize his emergency medical condition.

8. During an interview on 4/1/23 at 10:54 AM, ARNP I reported seeing Patient #5 for the first time the day after they were admitted to Hospital B. Patient #5 was having seizure activity in Hospital B's ED, their symptoms were discussed with a neurologist from a pediatric hospital, and they were started on Keppra. ARNP I reported according to Patient #5's chart they had recently been started on Abilify, Clonidine (a sedative that can be used to control symptoms of attention deficit hyperactivity disorder), and Quetiapine Fumarate (antipsychotic medication used to treat certain mental/mood conditions), and it was thought these medications could have contributed to their symptoms. ARNP I reported that Hospital B's physicians felt Patient #5's symptoms could have been Tardive Dyskinesia symptoms from these medications being started all at once, so these medications were discontinued during Patient #5's ED visit at Hospital B, and they were given Benadryl (antihistamine that reduces the effects of allergies). ARNP I reported after treatment was initiated, Patient #5 did not demonstrate any seizure activity during his overnight observation at Hospital B, had returned to his baseline condition, and was eating and drinking, so Patient #5 was discharged. Patient #5 had to be readmitted to Hospital B that same day due to continued seizure-like activity. The neurologist was consulted again, and the Keppra was discontinued, and 2 other medications were started for seizures. It was confirmed during Patient #5's hospitalization at Hospital B that they were having seizures according to the EEG results.

9. Hospital A failed to provide Patient #5 with an appropriate MSE sufficient to determine whether or not an emergency medical condition existed. Patient #5's MSE lacked the necessary laboratory analyses and advanced imaging to confirm whether or not Patient #5's diagnosis of tardive dyskinesia was the definitive diagnosis and not another pathologic process. Patient #5 went on to suffer progressive decline of their condition with multiple episodes of seizures and presented to another hospital for an appropriate MSC and stabilizing treatment which were indicated.