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CHERRY COUNTY HOSPITAL P O BOX 410, 510 NORTH GREEN ST VALENTINE, NE 69201 Sept. 7, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
An onsite complaint investigation



Based on record review, staff and provider interviews, review of the facility Medical Staff Rules and Regulation and the Emergency Treatment and Labor Act (EMTALA) policies the facility failed to ensure 1 of 20 sampled patients (Patient 5) received an adequate Medical Screening Exam (MSE) to ensure the patient was stable at discharge. The hospital's failure to provide an adequate MSE to ensure that Patient 5 did not an emergency medical condition.

Findings are:

A. Review of the facility policy dated 9/13/07 titled "Transfer and Emergency Examination" identified that the Medical Screening Examination (MSE) as "An examination within the capability of the Hospital's Emergency Department, including ancillary services routinely available to the Emergency Department, to determine with reasonable clinical confidence whether an EMC (Emergency Medical Condition) exists. The MSE must be provided by Qualified Medical Personnel, as defined at Section ll, B of this Policy and Procedure. A Qualified Medical Personnel is identified for the Critical Access Hospital as Physician, Physician Assistant, or Nurse Practitioner.

Review of the facility policy further identifies an EMC as:
1) Medical/Psychiatric: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, b) Serious impairment to bodily functions; or c) Serious dysfunction of any bodily organ or part.

Review of the hospital's Medicare Database Worksheet verified by the hospital administrator on 9/7/17 revealed the hospital's capabilities include a dedicated Emergency Department, pediatric services and no pediatric ICU.

Review of a closed medical record showed Patient 5 presented to the ED (Emergency Department) on 7/9/17 at 1338 (1:38 PM) complaining of abdominal pain. The pediatric patient's parents further informed staff that the patient had intermittent fevers with a temperature as high as 104 degrees in the last 48 hours, loose stools yesterday and yellow loose stools in the morning with some dark color, no vomiting, very fussy and complains of stomach ache.

A review of the finalized dictated 'emergency room Note' signed 7/19/17 at 1023 by the Physician Assistant (PA) - B which treated Patient 5 in the ED on 7/9/17 revealed, "The patient has been running a fever for the last 24-48 hours. Last night, it was actually up to 104 and they (parents) did call in and spoke with the staff last night who advised to continue with Tylenol and Ibuprofen. They have been alternating Tylenol and ibuprofen. (Patient 5) has had a decrease of oral intake in terms of food. Is still drinking water, but has had a decrease in that. (Patient 5) does not appear to be dehydrated. Has good tearing, good skin trugor and good capillary refill. (Parent) decided to have an evaluation today. (Parent) also reports that the child has had several watery loose stools today in addition to the decreased intake that (Patient 5) has been taking. Has had one episode here which appears to be concentrated urine without evidence of fecal matter. The child appears in moderate distress. (Parent) was concerned about the child's appendix. We discussed this at length."
PHYSICAL EXAM included:
-temperature 101 degrees; pulse 157; respirations 28; blood pressure 114/61 and oxygen saturation 98 % on room air.
-TM's (tympanic membrane- eardrum) both bulging with purulent fluid and some striation
-Abdomen is soft, has hyperactive bowel sounds
-Good skin turgor, good capillary refill of less than 2 seconds and good tearing. Appears to be well hydrated at this point
-LABS: White Blood Count (WBC) 18.8 [normal range 5.5-15.5]; Hemoglobin 15 [normal range 11-14.7]; Hematacrit (Hct) 43.9 [normal range 33-43]; Platelets (Plt) 323 [normal range 150-450]; Bands 7 with normal morphology [normal range 1-5]. Strep A Antigen- negative
ASSESSMENT:
1) Bilateral otitis media, 2) Enteritis, 3) Diarrhea
PLAN AND COURSE:
-Started on Amoxil 400/5ml 1-1/2 teaspoons here and then the rest of the bottle to go with 1-1/2 teaspoons BID (twice a day) for 10 days. Alternate Tylenol and ibuprofen. Push oral fluids. If not improved in 24 hours then return to the clinic or ED for follow up.

During a telephone interview on 9/7/17 at 11:15 AM with Physician Assistant - B (PA-B) that took care of the patient, stated, I remember I was here seeing other patients in the ED that day when this patient came in. The child looked ill, not gravely ill, was crying and tearing. The child was consolable by the parents and looked hydrated the color was good. The parents told me that the child wasn't eating good but was drinking, and had some diarrhea. We had seen GI (gastrointestinal) stuff the weekend with other patients. Did not get immunizations per parents choice. My exam showed an ear infection, runny nose and hyperactive bowel sounds. I ordered a Strep test because Strep can cause GI issues, also a CBC (complete blood count) and looked at the WBC, Plt, Hgb, no anemia, WBC slightly elevated but not abnormal morphology of cells, had a wide differential. Had ear infections, ok WBC, tummy issues we would see with gastroenteritis that we had been seeing. I was called to look at a specimen in the stool, what was in the (collection) hat looked like concentrated urine, no fecal matter was present. The parents were worried about the appendix, but in this age group it is very rare and the exam didn't show it. I did not do a CT (computerized tomography-mulitple pictures of inside the body) Scan due to it gives the child a "ton" of radiation and at this point the risk did not out weigh the benefit. It is shown that children with CT Scans can have a 25% increase in cancer later in life. I visited with the parents about the abdominal complaints and fussiness. They said the child is still taking water. The child looked hydrated so let them go home and told them to give it time. Use the Amoxil, Tylenol and Motrin and return immediately if not better or getting worse. "I did not feel that the child at any time had an EMC (emergency medical condition), it looked like gastro enteritis, was stable on discharge, taking fluids, well hydrated, the CBC looked ok with only a slightly elevated WBC, overall stable." I did find out that this child returned the next day and was transferred to a higher level of care and later passed away. I asked my self what else I could have done/run to pick it up sooner, if I did stool cultures, we have to send them out from here and would take 4 days to get back so, a CMP (complete metabolic profile) I don't know that would of helped. With the timeframe of the return visit the results would not have changed it.
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
2406
Based on medical record review, review of facility Medical Screening Examination (MSE) policy and staff interviews the facility failed to ensure 1 of 20 sampled patient records (Patient 5) received an adequate MSE to determine if the patient had an Emergency Medical Condition (EMC) at time of discharge home. This failure placed the patient at risk of harm. The patient was discharged with a potential EMC and returned within 24 hours and was transferred to a higher level of care.

Findings are:

A. Review of a closed medical record showed Patient 5 presented to the ED (Emergency Department) on 7/9/17 at 1338 (1:38 PM) complaining of abdominal pain. The pediatric patient's parents further informed staff that the patient had intermittent fevers with a temperature as high as 104 degrees in the last 48 hours, loose stools yesterday and yellow loose stools in the morning with some dark color, no vomiting, very fussy and complains of stomach ache.

A review of the the nurses notes 7/9/17 at 1338 from RN -A (registered nurse-A) revealed that upon inital assessment of Patient 5 in ED, the lung sounds were clear, heart rate regular, abdomen soft, bowel sounds present in 4 quadrants, right lower quadrant of abdomen tender to palpations. Patient 5's vital signs at time of ED admission were: temperature 101 degrees; pulse 157; respirations 28; blood pressure 114/61 and oxygen saturation 98 % on room air. The discharge temperature was 100.4, and crying so unable to get pulse.

A review of the finalized dictated 'emergency room Note' signed 7/19/17 at 1023 by the Physician Assistant -B (PA-B) which treated Patient 5 in the ED on 7/9/17 revealed, "The patient has been running a fever for the last 24-48 hours. Last night, it was actually up to 104 and they (parents) did call in and spoke with the staff last night who advised to continue with Tylenol and Ibuprofen. They have been alternating Tylenol and ibuprofen. (Patient 5) has had a decrease of oral intake in terms of food. Is still drinking water, but has had a decrease in that. (Patient 5) does not appear to be dehydrated. Has good tearing, good skin trugor and good capillary refill. (Parent) decided to have an evaluation today. (Parent) also reports that the child has had several watery loose stools today in addition to the decreased intake that (Patient 5) has been taking. Has had one episode here which appears to be concentrated urine without evidence of fecal matter. The child appears in moderate distress. (Parent) was concerned about the child's appendix. We discussed this at length."
PHYSICAL EXAM included:
-temperature 101 degrees; pulse 157; respirations 28; blood pressure 114/61 and oxygen saturation 98 % on room air.
-TM's (tympanic membrane- eardrum) both bulging with purulent fluid and some striation
-Abdomen is soft, has hyperactive bowel sounds
-Good skin turgor, good capillary refill of less than 2 seconds and good tearing. Appears to be well hydrated at this point
-LABS: White Blood Count (WBC-indicates an infection) 18.8 [normal range 5.5-15.5]; Hemoglobin (part of the blood that contains iron and carries oxygen from the lungs to tissues) 15 [normal range 11-14.7]; Hematacrit (Hct- indicates the percentage of red blood cells in the blood) 43.9 [normal range 33-43]; Platelets (Plt-part of the blood that is involved in clotting) 323 [normal range 150-450]; Bands 7 (can indicate infection) with normal morphology (structure of cells) [normal range 1-5]. Strep A Antigen (A bacteria that can cause infection)- negative
ASSESSMENT:
1) Bilateral otitis media (both ears are infected), 2) Enteritis (inflamation of the bowel causing diarrhea), 3) Diarrhea
PLAN AND COURSE:
-Started on Amoxil (an antibiotic) 400/5ml (400 milligrams per 5 mililiters of suspension) 1-1/2 teaspoons here and then the rest of the bottle to go with 1-1/2 teaspoons BID (twice a day) for 10 days. Alternate Tylenol and ibuprofen (medication for fever and pain). Push oral fluids. If not improved in 24 hours then return to the clinic or ED for follow up.

During a telephone interview on 9/7/17 at 11:15 AM with Physician Assistant - B (PA-B) that took care of the patient, stated, I remember I was here seeing other patients in the ED that day when this patient came in. The child looked ill, not gravely ill, was crying and tearing. The child was consolable by the parents and looked hydrated, the color was good. The parents told me that the child wasn't eating good but was drinking, and had some diarrhea. We had seen GI (gastrointestinal) stuff the weekend with other patients. This child did not get immunizations per parents choice. My exam showed an ear infection, runny nose and hyperactive bowel sounds. I ordered a Strep test because Strep can cause GI issues, also a CBC (complete blood count) and looked at the WBC, Plt, Hgb, no anemia, WBC slightly elevated but not abnormal morphology of cells, had a wide differential. Had ear infections, ok WBC, tummy issues we would see with gastroenteritis that we had been seeing. I was called to look at a specimen in the stool, the specimen was in the (collection) hat looked like concentrated urine, no fecal matter was present. The parents were worried about the appendix, but in this age group it is very rare and the exam didn't show it. I did not do a CT (computerized tomography-mulitple pictures of inside the body) Scan due to it gives the child a "ton" of radiation and at this point the risk did not out weigh the benefit. It is shown that children with CT Scans can have a 25% increase in cancer later in life. I visited with the parents about the abdominal complaints and fussiness. They said the child is still taking water. The child looked hydrated so let them go home and told them to give it time. Use the Amoxil, Tylenol and Motrin and return immediately if not better or getting worse. "I did not feel that the child at any time had an EMC (emergency medical condition), it looked like gastroenteritis, the child was stable on discharge, taking fluids, well hydrated, the CBC looked ok with only a slightly elevated WBC, overall stable." I did find out that this child returned the next day and was transferred to a higher level of care and later passed away. I asked my self what else I could have done/run to pick it up sooner, if I did stool cultures, we have to send them out from here and it would take 4 days to get back so, a CMP (complete metabolic profile) I don't know that would of helped. With the timeframe of the return visit the results would not have changed it.

An telephone interview on 9/7/17 at 10:30 AM with RN A, the nurse that cared for Patient 5 in the ED on 7/9/17 revealed, The child looked sick, like just didn't feel good, was having diarrhea; had tears in the eyes and the skin turgor was ok. I had the PA (PA-B) come and look at the child a couple of times before the child went home. The parents were distressed and I was concerned. Had a yellow brown loose stool mixed with urine while in the ED. The parents had a lot of questions before discharge about what to if, and PA-B visited with them and told them to bring the child right back if problem. The child acted like (gender) was having intermittent stomach cramping with the diarrhea, like had a tummy ache. I feel the child had a guarded condition on discharge because children can get so sick (crump) so quickly. Felt at the time of discharge the child was compensating, but miserable. I was concerned that the child could become more ill and decompensate.

The child was discharged at 1530 (3:30 PM) on 7/9/17 with the instructions to give Amoxil 400/5ml 1-1/2 teaspoons twice a day for 10 days; alternate Tylenol and ibuprofen for age; follow up with primary care physician in a week, push fluids, take medication as directed. The parents were told to return if worse or not improving.

An telephone interview on 9/7/17 at 10:45 AM with RN B, I had briefly seen the child on 7/9/17. That day the child looked sick, the parents reported the child having yellow loose stools, some dark in color and some low abdominal pain. The child was not fussy when being held. I listened to the child's lungs-they were clear, the heart rate was regular, abdomen was soft. I didn't look inside the mouth and not crying so unsure about tears, just looked sick. I put a hat in the toilet and gave them a urinal before I left. .

C. Review of the 9/13/07 facility policy titled "Transfer and Emergency Examination" identified that a Medical Screening Examination as "An examination within the capability of the Hospital's Emergency Department, including ancillary services routinely available to the Emergency Department, to determine with reasonable clinical confidence whether an EMC (Emergency Medical Condition) exists. The MSE must be provided by Qualified Medical Personnel, as defined at Section ll, B of this Policy and Procedure. A Qualified Medical Personnel is identified for the Critical Access Hospital as Physician, Physician Assistant, or Nurse Practitioner.