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CAROMONT REGIONAL MEDICAL CENTER 2525 COURT DR GASTONIA, NC 28052 July 2, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on hospital policy reviews, closed medical record reviews, physicians and staff interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24.

The findings include:

1. Based on hospital policy review, closed medical record review and interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 1 sampled patients returning to the DED at 48 hours ( #7).

~ Cross refer to 489.24(r) and 489.24(c) Medical Screening Examination - Tag A2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, closed medical record review and interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 1 sampled patients returning to the DED at 48 hours ( #7).

The Findings include:

Review of the DED policy "Emergency Medical, Treatment and Labor Act (EMTALA) Compliance, revised 11/12, Number 155.00" revealed "When an individual presents or is brought to the Emergency Department of (sss-name of hospital) and a request is made on the individuals' behalf for examination and treatment of a medical condition, a physician / physician assistant will provide a medical screening examination within the capabilities of the Hospital, including ancillary services routinely available to the Emergency department, for the purpose of determining the presence or absence of an Emergency Medical Condition...2. Medical Screening Exam - The initial and on-going evaluation of the presenting patient conducted by a physician and / or physician assistant. Evaluation includes history, physical examination, appropriate testing, completion of appropriate documentation and evaluation of the patient, within the capabilities of this Hospital utilizing those facilities routinely available to the Emergency Department, including the use of the indicated on-call physicians as appropriate, to determine whether the patient has an Emergency Medical Condition".

Review of Hospital policy "Assessment of the Emergency Department Patient Policy revised 3/13, Number: A - 6" revealed "To define guidelines for the emergency department Registered Nurse (ED RN) for the assessment of the Emergency Department (ED) patient...1. All patients admitted to the ED will have the following documentation...B). Any infant 3 months or less presenting to triage with either an actual or reported temperature of 100.3 or greater will be triage Level 2 and taken back to a treatment room...G). < 2 years--head circumference and length". Further review of the policy revealed Infants normal range of vital signs by age, infants 1 - 12 months systolic blood pressure between 70-95, Pulse rate 100-120 beats per minute, Respiratory rate 25-50, O2 saturation greater than 95% and Temperature greater than 97.8 or less than 99.0. Policy review revealed if the vital signs fall outside of temperature range, check rectal temperature and if second temperature is abnormal notify the RN to recheck and if it still is abnormal RN to notify the MD immediately.

1. First visit. Medical record review of Patient #7 revealed the patient a 9 week old infant (MDS) dated [DATE] at 0234 with a chief complaint of vomiting. Medical record review revealed the patient was brought in by both parents. Record review revealed at 0234 during triage the patient's vital signs were Pulse 165, Respirations 30, and temperature 99.7 rectally and acuity level of Blue level 3. Record review revealed the infant weighed 4.99 kgs (11 pounds 0 ounces). Record review revealed the mother told the nurse at triage that the baby was gagging with vomiting and "she hasn't been eating very well and she hasn't had a wet diaper in a few hours". Record review revealed the MSE was started at 0254 and ended at 0306. Review of the MSE revealed the patient was " a healthy nontoxic...discussed nasal toilet and appropriate feeding sizes". Record review revealed patient #7 was given Zofran (anti nausea medication) 0.5 mg/kg by mouth at 0319. Review of the MSE revealed the patient was discharged 0427 with a diagnosis of Upper respiratory illness and nausea and vomiting. Record review did not reveal any documentation of head circumference, head length or vital signs prior to the patient being discharged .

2. Second visit. Medical record review revealed patient #7 (MDS) dated [DATE] at 0235 (approximately 48 hours after first visit). Record review revealed the patient was brought in by both parents with a chief complaint of "seen 2 days ago still has diarrhea ('super weight loss') ". Review of triage at 0236 revealed pulse was 176, Respirations were 30 and Temperature was 100.2 rectally. Record review revealed patient's weight was 4.59 kgs (10 pounds 2 ounces). Record review revealed the patient's mother stated "was seen here 2 days ago for vomiting and given medication, she is no longer having the vomiting but she still has diarrhea and having super weight loss." Review of triage documentation revealed the infant was triaged yellow level 2 (higher level than previous visit). Record review revealed the patient was placed back in the waiting area. Record review revealed the patient was placed in a DED bed at 0455. Review of documentation by nursing revealed at 0503 "behavior is listless, mother states child was vomiting and seen in the ER Thursday morning and given Zofran and pedialyte, mom states pt (patient) has not been vomiting but has been having lots of diarrhea, mom says she has very loose stool Thursday. Mom states child had 3-4 loose stools in 3 hours. Mom says child has lost about 8-9 oz (ounces) since the watery diarrhea started". Record review revealed at 0452 vital signs were Pulse 169, Respirations 28 Temperature 100.6 Rectally and Oxygen saturation (O2)was 96% and at 0500 Pulse 158, Respirations 26 temperature 98.6 rectally and O2 was 96%. Medical record review did not reveal any documentation of head circumference or length. Record review revealed the DED physician #1 started the MSE at 0529. Review of the MSE revealed the chief complaint of diarrhea, "seen yesterday in ED for viral synd/URI (syndrome/upper respiratory infection) F/U (Follow up) PCP (primary Care Physician) benign exam...Afebrile". Further review revealed documentation by the physician revealed the triage tachycardia (heart rate > than 100) "resolved on MD exam". Review of the MSE revealed the clinical Impression was Diarrhea and Viral syndrome. Record review revealed Physician #1 ordered the patient for discharge at 0543. Record review revealed at 0550 Pulse 160, Respirations 28 Temperature 98.9 TE (tympanic). Record review revealed the patient was discharged home at 0551. Record review revealed no documentation of assessment of the infant's head or other testing prior to discharge.

Interview with DED Physician #1 on 07/01/2015 at 0900 revealed he was the DED attending physician for patient #7. The interview revealed he was the DED physician for patient #7 on each visit, first visit on 06/04/2015 and second visit on 06/06/2015. The interview revealed during the first visit he gave the patient a PO (by mouth) challenge of 2 ounces of pedialyte. The interview revealed the parents had given the complete 2 ounces and he told them 2 ounces would be too much and may cause vomiting and 1 ounce should be given at a time. The interview revealed on 06/06/2015 (2nd DED visit) the nursing documentation at triage was available for his review. The interview revealed he did not remember if the documentation of "super weight loss" was in the chart system when he evaluated patient #7. The interview revealed he was aware of weight loss because when he walked into the exam room the "Dad said she is losing ounces". The interview revealed he was aware of the patient's weight on the second was 10 pounds 2 ounces. The interview revealed documentation from the first visit was in the system and was available for his review. The interview revealed it was not communicated to him of the temperature at triage of 100.2 and then going up to 100.6. The interview revealed he did not have this documentation because he documented the patient was "afebrile". The interview revealed for patient #7's age group the average pulse would be expected between 100 -130. The interview revealed evaluating the fontanel would be routinely done but the infant's skin was warm, dry, turgor was ok so the assessment of the fontanel would be way down the line to be checked.

Interview with RN #1 revealed she provided care to Patient #7 on 06/06/2015 visit. The interview revealed she remembered the infant. The interview revealed patient #7 was a "sick baby did not feel good". The interview revealed she did not remember seeing the temperature of 100.6 in the medical record prior to her taking the infants vital signs. The interview revealed she did not see a "sunken" fontanel.

Medical record review from Hospital B revealed patient #7 presented to Hospital B's DED on 06/07/2015 at 1428 with a chief complaint of diarrhea and dehydration. Record review revealed on arrival the patient was lethargic and had a temperature of 102.7 F, heart rate of 200, Respiration rate of 48 and anterior fontanel was sunken. Record review revealed lab testing revealed patient #7's blood gas levels were PH 7.04 (Critical value), Bicarbonate 10.5 (Critical value). Record review revealed the patient was admitted to the Pediatric intensive care unit with admission diagnosis of Metabolic acidosis and severe dehydration.

NC 806