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Based on review of policies and procedures, medical record review, staff and provider interviews the Acute Care Facility (ACF) failed to follow their policies and procedures for 3 (P3A, P3B, and P11) of 20 sampled patient medical records to ensure complete medical screening exams (MSE) were provided to rule out the presence of an emergency medical condition (EMC) prior to discharge. This failed practice has the potential to cause harm or death due to delayed treatment or transfer of all patients that present to the ACF Emergency Department (ED). According to facility provided information the ED treats an average of 7, 936 patients per month.

See A2406 and 2407 cited that also resulted in the Emergency Medical Treatment and Active Labor Act (EMTALA) obligations to not be met.

Findings include:

A. Review of the facility policy, "Mental Health Evaluation-Emergency Services," effective 11/11/2022 revealed, "Medical staff documentation includes all of the elements of the medical screening examination including observations and the diagnostic test results supporting a conclusion that an emergency medical condition does or does not exist."

-"Emergency Department and Mental Health staff will collaboratively assure appropriate treatment, admission/discharge and transfer procedures are implemented."

B. Review of the facility policy, "EMTALA," effective 6/2/2023 revealed:
-Emergency medical condition (EMC): "A condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, symptoms of substance abuse, intoxicated individuals, and individuals expressing suicidal or homicidal thoughts or gestures such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health (or the health of an unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or that may pose a threat to the health and safety of the woman or unborn child."

-Medical screening examination (MSE): "Process required to reach, with reasonable clinical confidence and not on the basis of an individual's source of payment or ability to pay, the point at which it can be determined whether a medical emergency does or does not exist." ." ..... "A medical screening examination is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the person's needs and shall continue until they are stabilized for discharge or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer."

-"The following are always considered emergency medical conditions (EMC) and must be screened and treated." ... ...Psychiatric disturbances, Symptoms of substance abuse, and Intoxication.

-Medical Screens will include: "Appropriate physical examination, including vital signs, the presenting complaint, potentially affected systems, known chronic conditions, and appropriate psychosocial information." "Supportive diagnostic evaluation according to presenting medical complaint."

C. Review of the facility policy, "Medical Staff Rules & Regulations Excerpts pertaining to EMTALA & QMP," approved by the Board of Trustees on 1/23/2023 revealed, "Any patient determined to have a psychiatric disorder (i.e., a clinically significant disturbance in the individuals cognition, emotion regulation, or heavier that reflects a dysfunction in the psychosocial, biological, or developmental processes underlying the individual's mental functioning may be admitted to the psychiatric area of the Medical Center when medical conditions permit, as determined by the Admitting Practitioner. If there are no accommodations available in this area, the patient shall be transferred, if possible, to another institution where suitable facilities are available in accordance with EMTALA procedures."

D. Review of Patient 3A (P3A)'s medical record (1/2/2024 at 9:12 AM) revealed P3A presented to the ACF ED on 11/18/2023 at 9:44 PM via ambulance after being found stumbling down the street intoxicated. According to the facility policy, "EMTALA," effective 6/2/2023, "The following are always considered emergency medical conditions (EMC) and must be screened and treated ....Psychiatric disturbances, Symptoms of substance abuse, and Intoxication." The Physician Assistant-A (PA-A) Emergency Department (ED) provider note titled physical exam lacked documentation of mental health screening, labs, drug or alcohol screening, consults, or imaging prior to disposition of discharge. A review of P3A's entire medical record lacked evidence of documentation of discharge criteria set by PA-A prior to P3A discharge, confirmed by Registered Nurse-A (RN-A) during an interview on 1/2/2024 at 3:25PM.

-Review of Patient 3B (P3B)'s medical record (12/28/2023 at 12:21PM) revealed P3B presented to the ACF ED on 11/20/2023 at 9:14PM for a mental health evaluation. The Advanced Practice Registered Nurse (APRN) ED provider note lacked evidence of labs, drug or alcohol screening, or imaging. P3B 11/20/2023 Mental Health Emergency Department (MHED) medical record lacked evidence of RN-D, RN-E, APRN, or PA-B collaboratively assuring appropriate treatment, admission/discharge and transfer procedures were implemented prior to discharge. The documentation from APRN and PA-B lacked evidence of supportive diagnostic evaluation according to presenting medical complaint of, "mental health problem-pt (patient) states is here for a mental health eval. Intoxicated and aggressive in triage. ED security present." The APRN ED course & medical decision-making documentation revealed, "Unfortunately, [Detox Center A] does not have any beds at this time. [3B] was evaluated by the psychiatry team. Mother is going to try at [Detox Center B]. [3B] was given 1 dose of Zyprexa (antipsychotic medication, helps regulate mood, behavior and thoughts). Discharge with provisional diagnosis of alcohol use disorder." P3B 11/20/2023 ED medical record lacked evidence of, "If there are no accommodations available in this area, the patient shall be transferred, if possible, to another institution where suitable facilities are available in accordance with EMTALA procedures."

E. During an interview on 1/3/2024 at 7:27AM RN-D revealed that RN-D's interactions with P3B were prior to RN-E assessments, and RN-D was not the primary nurse assigned to P3B. RN-D recalled that P3B was coming to the nurses' station, "agitated, wanting to leave, unwilling to stay in an area, and attempted to redirect P3B back to MHED room [security was called to assist]." P3B medical record from 11/20/2023 lacked notification documentation of communication between RN-D and RN-E, or RN-D and APRN or PA-B regarding the 10:01PM behavioral event by P3B; RN-D did not recall communicating P3B's behavioral event to RN-E, APRN or PA-B.

-During an interview on 1/3/2024 at 10:02AM APRN revealed the APRN consulted psychiatry [PA-B] and did not recall speaking to RN-E or PA-B regarding P3B. The APRN stated the Qualified Medical Professional (QMP) has access to the medical record and collaborates with psychiatry who makes the final decision on the disposition (decision to discharge, transfer or admit the patient) of the patient.

-During an interview on 1/3/2024 at 8:14AM with PA-B revealed PA-B was consulted by APRN, PA-B did not see P3B in person, and did not access P3B's medical record at the time of consult. PA-B communicated with RN-E via one telephone call regarding P3B. PA-B did not recall if RN-E reported P3B's 10:01PM behavioral event that resulted in security involvement.

-During an interview on 1/3/2024 at 10:33AM with RN-E revealed RN-E was the assigned QMP for P3B and did not recall if RN-D reported P3B's 10:01PM behavioral event that resulted in security involvement. RN-E unaware of security involvement with P3B and did not report to PA-B during the psychiatric consult phone call to determine patient disposition (decision to discharge, transfer or admit the patient). RN-E confirmed no lab, drug or alcohol screen were ordered by APRN or PA-B during P3B's entire 11/20/2023 ED visit.


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F. Review of Patient 11 (P11)'s medical record review revealed an admission blood pressure of 102/71 at 10:23PM on 9/8/23. While in the ED P11 received 2 liters of IV fluids with partial vitals that included pulse, blood pressure, MAP and oxygen saturation being checked at irregular intervals. P11's blood pressure and Mean Arterial Pressure (MAP) continued to be low. The medical record lacks evidence of an evaluation prior to discharge as part of the ongoing process of the medical screening examination according to the facilities policy EMTALA effective 6/2/23.

G. During an interview on 1/3/24 at 1:00PM, Medical Doctor-A (MD-A) revealed that he did not remember P11. MD-A was able to review P11's medical record for the 9/8/23 visit prior to interview. MD-A stated that his shift was 3PM-12AM that day and he would have reported off to the oncoming provider (MD-B). The medical record lacks documentation that a handoff of providers was completed or that MD-B evaluated P11 prior to discharging.

Based on hospital policy and procedure review, medical record reviews, medical staff and staff interviews the Acute Care Facility (ACF) failed to ensure that 2 (P3B, and P11) of 20 sampled patients medical records received a complete Medical Screening Examination (MSE) to determine the presence of an emergency medical condition (EMC) prior to discharge. This failed practice has the potential to cause harm or death due to delayed treatment to all patients that present to the ACF Emergency Department (ED). According to facility provided information the ED treats an average of 7, 936 patients per month.

See A2400 and A2407 cited that also resulted in the Emergency Medical Treatment and Active Labor Act (EMTALA) obligations to not be met.

Findings Include:

A. Review of the facility policy, "Mental Health Evaluation-Emergency Services," effective 11/11/2022 revealed, " ... ...the physician is responsible for the conclusion of the medical screening examination and the determination of whether the patient has an emergency medical condition. When an EMC is determined to exist, continued stabilizing and evaluative care will be rendered within the capabilities of the Medical Center."

-"In addition to those conditions described in the EMTALA procedure, all patients presenting with psychiatric disturbances presenting at an Emergency Department are declared by law to be emergencies requiring a medical screen, to exclude organic causes and additional psychiatric assessment of the patient's condition, to provide for stabilization within the capabilities of the institution." ..... "The following conditions are examples of Unstable Psychiatric Conditions, as defined by CMS ... ...Danger to self or others .....Change in mental status (must rule out organic causes, intoxication, masked conditions."

-"Emergency Department and Mental Health staff will collaboratively assure appropriate treatment, admission/discharge and transfer procedures are implemented."

"Medical staff documentation includes all of the elements of the medical screening examination including observations and the diagnostic test results supporting a conclusion that an emergency medical condition does or does not exist."

B. Review of the facility policy, "EMTALA," effective 6/2/2023 revealed:
-Emergency medical condition (EMC): "A condition manifesting itself by acute symptoms of sufficient severity (including .....psychiatric disturbances, symptoms of substance abuse, intoxicated individuals ... ....the absence of immediate medical attention could reasonably be expected to result in placing the individual's health ... ...in serious jeopardy."

-Medical screening examination (MSE): "Process required to reach, with reasonable clinical confidence and not on the basis of an individual's source of payment or ability to pay, the point at which it can be determined whether a medical emergency does or does not exist."

-"A medical screening examination is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the person's needs and shall continue until they are stabilized for discharge or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer."

-"The following are always considered emergency medical conditions (EMC) and must be screened and treated." ... ...Psychiatric disturbances, Symptoms of substance abuse, and Intoxication.

-Medical Screens will include: "Appropriate physical examination, including vital signs, the presenting complaint, potentially affected systems, known chronic conditions, and appropriate psychosocial information." "Supportive diagnostic evaluation according to presenting medical complaint."

C. Review of Patient 3B (P3B)'s medical record (12/28/2023 at 12:21PM) revealed P3B presented to the ACF ED on 11/20/2023 at 9:14PM for a mental health evaluation. The APRN ED provider note revealed P3B was a return visit within 24 hours [P3A was discharged 11/19/2023 at 2:07AM]. The APRN ED provider note revealed P3B a past medical history (PMH) of alcohol abuse, anxiety, bipolar, depression, drug abuse, and psychosis. P3B history of present illness (HPI) documented by the APRN revealed, " ...[P3B] Patient admits to acute alcohol intoxication. States that he also uses methamphetamines and weed. Mother is concerned as he has a history of schizophrenia and is not taking any of his medications at this time. The APRN ED provider note physical exam documentation revealed, "Mother and family member at bedside, patient is only wearing pants, no shoes or socks, no shirt, disheveled, walking around the room, comes close to my face multiple times, intrusive." [Danger to others]. The ED APRN medically cleared P3B for the Mental Health ED (MHED) and consulted psychiatry to complete the MSE on 11/20/2023 at 9:56PM.

-P3B was transferred from the ED to the MHED within the ACF. RN-D documented, "Pt [patient] became agitated and was unable/unwilling to listen to redirection from MHED staff, ED security called to assist with pt [patient]," on 11/20/2023 at 10:01PM. A review of RN-E mental health assessment revealed RN-E documented P3B's admission type as voluntary, for "alcohol sucks," ... mental status behavior characteristics as, "unwilling to participate, hyperactive, intrusive, guarded, resistant to care;" ... "concentration, insight, and judgement as impaired," ... decreased appetite, disturbed/interrupted sleep on 11/20/2023 at 10:48PM. [Danger to others].

-The 11/20/2023 MHED medical record for P3B lacked evidence that a physician from the psychiatry team directly evaluated P3B to complete the MSE per policy, and no documentation or acknowledgement/signature from PA-B the consulted psychiatry regarding decision making of P3B disposition prior to discharge or thereafter.

-RN-E designated as the (qualified medical professional) QMP documented the Mental Health Emergency Department (MHED) plan after assessment naming psych consulted as PA-B which revealed a plan of discharge with alcohol use disorder as the diagnosis that was co-signed by a psychiatric MD on 11/21/2023 at 7:26PM. [19 hours and 56 minutes after P3B was discharged from the MHED on 11/20/2023 at 11:30PM].

D. During an interview on 1/3/2024 at 7:27AM RN-D revealed that RN-D's interactions with P3B were prior to RN-E assessments, and RN-D was not the primary nurse assigned to P3B. RN-D recalled that P3B was coming to the nurses' station, "agitated, wanting to leave, unwilling to stay in an area, and attempted to redirect P3B back to MHED room [security was called to assist]." P3B medical record from 11/20/2023 lacked notification documentation of communication between RN-D and RN-E, or RN-D and APRN or PA-B regarding the 10:01PM behavioral event by P3B; RN-D did not recall communicating P3B's behavioral event to RN-E, APRN or PA-B.

-During an interview on 1/3/2024 at 10:02AM APRN revealed the APRN consulted psychiatry [PA-B] and did not recall speaking to RN-E or PA-B regarding P3B. The APRN stated the QMP has access to the medical record and collaborates with psychiatry who makes the final decision on the disposition (decision to discharge, transfer or admit the patient) of the patient.

-During an interview on 1/3/2024 at 8:14AM PA-B revealed PA-B was consulted by APRN, PA-B did not see P3B in person, and did not access P3B's medical record at the time of consult. PA-B communicated with RN-E via one telephone call regarding P3B. PA-B did not recall if RN-E reported P3B's 10:01PM behavioral event that resulted in security involvement.

-During an interview on 1/3/2024 at 10:33AM RN-E revealed RN-E was the assigned QMP for P3B and did not recall if RN-D reported P3B's 10:01PM behavioral event that resulted in security involvement. RN-E unaware of security involvement with P3B and did not report to PA-B during the psychiatric consult phone call to determine patient disposition (decision to discharge, transfer or admit the patient). RN-E confirmed no lab, drug or alcohol screen were ordered by APRN or PA-B during P3B's entire 11/20/2023 ED visit.


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E. Review of Patient 11's (P11) medical record from Facility -A revealed on 9/8/2023 at 10:23PM P11 presented to the ED at Facility A via ambulance. P11 is an 18-year-old who lives at the dorm. P11 had complaints of nausea, vomiting, cough and almost passing out at the dorm. The RN (Registered Nurse) at the dorm called 911. Upon admission to the ED P11's vitals were Temp (T) 99.5 F, Pulse (P) high at 135 (normal average 60-100 ), Respirations (R) 18, blood pressure (BP) 102/71 oxygen saturation (SPO2) 96%. MD-A evaluated P11. The assessment revealed that P11's lungs were clear in all lung fields no abnormal lung sounds heard, bowel sounds were positive and abdomen was soft, nontender and nondistended, skin was warm and dry. Orders included, CBC (complete blood count a test that provides information about the cells in a person's blood), BMP (basic metabolic panel is a blood test that measures glucose (sugar) electrolytes and how well the kidneys are working), COVID nasal swab, IV (intravenous) fluids, IV Zofran (medication to treat nausea and vomiting) and an EKG (electrocardiogram a recording of the heart's electrical activity) were ordered.

Abnormal lab results include potassium (a blood chemical that if low can cause fatigue, muscle cramps and abnormal heart rhythm) low at 3.2 (normal range 3.5-5.3) Creatinine (a waste product produced by your body that is filtered out by the kidneys. A high level can be a sign of a possible kidney problem.) high at 1.93 (normal range 0.50-1.40) white blood cells (part of the blood to help fight infection) low at 3.22 (normal range 4-10) platelet count (part of the blood that forms clots and stops or prevents bleeding) low at 79 (normal range 150-400) band neutrophils % (elevated concentration is the result of infection or inflammation) high at 60.2% (normal range 0.0-20.0%) lymphocytes, absolute (low levels can place the patient at higher risk of infection) low at 0.22 (normal range 0.80-3.30) vacuolated neutrophils (often indicators of an infection such as sepsis) abnormal with cells present (normal results cells absent). The COVID nasal swab was negative. The EKG was interpreted as sinus tachycardia (fast heart rate) with no acute ischemic changes (no reduction of oxygen rich blood flow to the heart - causes a change to the hearts electrical activity).

While in the ED P11 was receiving IV fluids. During this time P11's P, SPO2, BP and MAP (Mean Arterial Pressure- the average arterial pressure throughout one cardiac cycle. Normal range is 70-100. If below 60 there is a concern that there won't be enough pressure to perfuse vital organs) are documented in the medical record.
Documented vital signs include
9/8/23 at 11:30PM: P 122, SPO2 97%, BP 90/35, MAP 50 (P and BP marked as abnormal)
9/9/23 at 12:17AM: P 121, SPO2 100%, BP 85/54 MAP 64 (P marked as abnormal)
9/9/23 at 12:30AM: P 115, SPO2 98%, BP 85/45, MAP 58 (P and BP marked as abnormal)
9/9/23 at 12:45AM: P 115, SPO2 99%, BP 93/42, MAP 57 (P and BP marked as abnormal)
9/9/23 at 1:30AM: P 109, SPO2 95%, BP 91/47, MAP 59 (BP marked as abnormal)

The medical record lacks evidence of MD-A or MD-B being notified of abnormal vital sign results during P11's ED visit.
At 12:03 AM on 9/9/23 MD-A set P11's disposition to discharge home in the electronic medical record (EMR) and sent an order for Zofran (medication to treat nausea and vomiting) to the pharmacy. At 1:48AM MD-B changed the patient status in the EMR to "Patient Ready to Go." The medical record lacks documentation that MD-B continued the ongoing process of the MSE with an evaluation of P11 prior to discharge to determine if the EMC had been resolved. RN-F was the discharging nurse that reviewed the after-visit summary (AVS) with P11 and family. The medical record lacks evidence of a full set of vitals (a full set of vitals includes temperature, pulse, respirations, blood pressure, oxygen saturation) prior to discharge. P11 was discharged home with parents at 2:00AM on 9/9/23.

F. Review of medical record from Facility-B reveals that P11 presented to the ED on 9/9/23 at 4:00PM (14 hours after discharge from Facility-A). P11 chief complaint included not feeling well for the past couple of days, headache, body aches, abdominal pain, dizziness, nausea, and fevers. Triage vital signs were T 97.9 oral, P 104, R 20, BP 94/39, MAP 57, SPO2 100% on room air and pain rating of 4 out of 10 in the upper abdomen. P11 also admitted to new onset diarrhea with 7 episodes on 9/9/23. Assessment was completed. Labs, radiology and IV fluid bolus were ordered.

Abnormal labs included WBC (white blood count- can indicate an infection) high at 18 (normal range 4-10), Platelets (help with clotting) low at 96 (Normal range 150-450), Glucose (sugar) high at 114 (normal range 70-99), Sodium (low sodium can cause nausea, vomiting, loss of energy and confusion) low at 131 (Normal range 136-145), BUN (a product in the body removed by the kidneys elevated levels can indicate the kidneys aren't working well) high at 30 (Normal Range 6-22), Creatinine (a waste product produced by your body that is filtered out by the kidneys. An elevated level can be a sign of a possible kidney problem.) high at 2.51 (Normal range 0.50-1.40), AST (an elevated level can indicate liver disease) high at 65 (Normal range 0-41), high sensitivity CRP (c-reactive protein high levels can indicate a serious infection) high at greater than 300 (Normal range 0.0-5.0), Lactate (an elevated level can indicate organs are not functioning properly) high at 3.3 (Normal range 0.7-2.1) Procalcitonin (a substance the body produces in response to bacterial infection, elevated levels can indicate a serious infection or sepsis) high at greater than 100 (Normal range less than 0.08).

While in the ED at Facility-B P11 received 5 liters of IV fluid, IV Zosyn (antibiotic), IV Vancomycin (antibiotic) and a Levaquin tablet (antibiotic). P11 was also started on a levophed (an IV medication used to treat low blood pressure ) infusion. P11 was transferred to Facility-C via Advanced Life Support (ALS) ambulance at 8:50PM. Vital signs prior to transfer were T 98.6, P 91, R 30, BP 102/47 MAP 65. Facility-B documented the transferring diagnosis as Septic shock without obvious source.

G. During an Interview on 1/3/23 at 2:30PM, RN-F revealed that in the ED the EMR is set up to run the sepsis screening in the background when criteria information is entered. In the ED the system runs the qSOFA (quick sequential organ failure assessment) screen. Criteria used for screening include altered mental status (AMS), respiratory rate greater than 22 and hypotension (low blood pressure) SBP (systolic blood pressure - the top number of blood pressure) less than 100. RN-F confirmed that since P11 did not have mental status and respiratory rate entered with documented vital signs the qSOFA screen did not run. RN-F stated that expectation for vital signs is hourly. The hourly vital signs expectation is to include temperature and respiratory rate. RN-F stated there was not a policy for vital signs only that they are a care expectation. RN-F confirmed that P11 was not screened by the EMR using the qSOFA screen due to no respirations or the altered mental status being addressed during the ED visit after the initial set of vitals.

H. During an interview on 1/3/23 at 1:00PM, MD-A revealed that he does not remember P11 however he was able to review the medical record. MD-A states that looking at the chart P11 looked more viral sick than bacterial sick. P11s lung sounds were clear, and a chest x-ray was not indicated. MD-A felt that with an elevated creatinine and the increase in P11's pulse that P11 was dehydrated. MD-A was asked if P11's blood pressure was concerning, and MD-A replied that the blood pressure could have been due to the dehydration. When asked if MD-A thought P11's lab should have been redrawn due to the EDTA-medicated platelet clumping (an anticoagulant used in blood collection tubes can cause the platelets to clump). MD-A responded that he did not feel that the lab needed to be redrawn. MD-A stated that he worked 3P-12A on 9/8/23 so he was not working when P11 was discharged. MD-A stated that he would have reported off to the oncoming medical provider at the end of his shift, but he does not recall P11 or reporting off.

Based on medical record review, staff interviews and policy review the facility failed to ensure that 1 (P11) of 20 sampled patient medical records received necessary stabilizing treatment for an EMC within the capabilities of the facility. This failed practice has the potential to cause harm or death due to delayed treatment to all patients that present to the ACF ED. According to facility provided information the ED treats on average 7,936 patients per month.

See A2400 and 2406 cited that also resulted in the Emergency Medical Treatment and Active Labor Act (EMTALA) obligations to not be met.

Findings include:

A. Review of facility policy "EMTALA", effective 6/2/2023 revealed, that the MSE is an ongoing process, and the record must reflect continued monitoring according to the person's needs and shall continue until they are stabilized for discharge or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer. The MSE will include an appropriate physical examination including vital signs.

B. Review of Patient 11's (P11) medical record from Facility-A revealed on 9/8/2023 at 10:23PM P11 presented to the ED at Facility A via ambulance. P11 is an 18-year-old who lives at the dorm. P11 had complaints of nausea, vomiting, cough and almost passing out at the dorm. The RN (Registered Nurse) at the dorm called 911. Upon admission to the ED P11's vitals were T 99.5 F, P high at 135 (normal average 60-100), R 18, BP 102/71 (normal range 100-139/50-89) and oxygen saturation (SpO2) 96% (normal range 90%-100%). MD-A evaluated P11. The assessment revealed that P11's lungs were clear in all lung fields no abnormal lung sounds heard, bowel sounds were positive, and abdomen was soft, nontender and nondistended, skin was warm and dry. Orders included, CBC (complete blood count a test that provides information about the cells in a person's blood), BMP (basic metabolic panel is a blood test that measures glucose (sugar) electrolytes and how well the kidneys are working), COVID nasal swab, IV (intravenous) fluids, IV Zofran (medication to stop nausea) and an EKG (electrocardiogram a recording of the heart's electrical activity) were ordered.

Abnormal lab results include potassium (a blood chemical that if low can cause fatigue, muscle cramps and abnormal heart rhythm) low at 3.2 (normal range 3.5-5.3) Creatinine (a waste product produced by your body that is filtered out by the kidneys. A high level can be a sign of a possible kidney problem.) high at 1.93 (normal range 0.50-1.40) white blood cells (part of the blood to help fight infection) low at 3.22 (normal range 4-10) platelet count (part of the blood that forms clots and stops or prevents bleeding) low at 79 (normal range 150-400) band neutrophils % (elevated concentration is the result of infection or inflammation) high at 60.2% (normal range 0.0-20.0%) lymphocytes, absolute (low levels can place the patient at higher risk of infection) low at 0.22 (normal range 0.80-3.30) vacuolated neutrophils (often indicators of an infection such as sepsis) abnormal with cells present (normal results cells absent). The COVID nasal swab was negative. The EKG was interpreted as sinus tachycardia (fast heart rate) with no acute ischemic changes (no reduction of oxygen rich blood flow to the heart - causes a change to the hearts electrical activity).

While in the ED P11 was receiving IV fluids. During this time P11's BP, MAP (Mean Arterial Pressure- the average arterial pressure throughout one cardiac cycle. Normal range is 70-100. If below 60 there is a concern that there won't be enough pressure to perfuse vital organs) P, and SPO2 are documented in the medical record.

Documented vital signs include
9/8/23 at 11:30PM: P 122, SPO2 97%, BP 90/35, MAP 50 (P and BP marked as abnormal)
9/9/23 at 12:17AM: P 121, SPO2 100%, BP 85/54 MAP 64 (P marked as abnormal)
9/9/23 at 12:30AM: P 115, SPO2 98%, BP 85/45, MAP 58 (P and BP marked as abnormal)
9/9/23 at 12:45AM: P 115, SPO2 99%, BP 93/42, MAP 57 (P and BP marked as abnormal)
9/9/23 at 1:30AM: P 109, SPO2 95%, BP 91/47, MAP 59 (BP marked as abnormal)

The medical record lacks evidence of MD-A (shift from 3PM-12AM) or MD-B (shift started at 12AM on 9/9/23) being notified of abnormal vital sign results during P11's ED visit. At 12:03 AM on 9/9/23 MD-A set P11's disposition to discharge home in the electronic medical record (EMR) and sent an order for Zofran to the pharmacy. At 1:48AM MD-B changed the patient status in the EMR to "Patient Ready to Go." The medical record lacks documentation that MD-B continued the ongoing process of the MSE with an evaluation of P11 prior to discharge to determine if the EMC had been resolved. RN-F was the discharging nurse that reviewed the after-visit summary (AVS) with P11 and family. The medical record lacks evidence of a full set of vitals prior to discharge. P11 was discharged home with parents at 2:00AM on 9/9/23.

C. Review of medical record from Facility-B reveals that P11 presented to the ED on 9/9/23 at 4:00PM (14 hours after discharge from Facility-A ED). P11's chief complaint included not feeling well for the past couple of days, headache, body aches, abdominal pain, dizziness, nausea, and fevers. Triage vital signs were T 97.9 oral, P 104, R 20, BP 94/39, MAP 57, SPO2 100% on room air and pain rating of 4 out of 10 in the upper abdomen. P11 also admitted to new onset diarrhea with 7 episodes on 9/9/23. Assessment was completed. Labs, radiology and IV fluid bolus were ordered.

Abnormal lab results include WBC (white blood count- can indicate an infection) high at 18 (normal range 4-10), Platelets (help with clotting) low at 96 (Normal range 150-450), Glucose (sugar) high at 114 (normal range 70-99), Sodium (low sodium can cause nausea, vomiting, loss of energy and confusion) low at 131 (Normal range 136-145), BUN (a product in the body removed by the kidneys elevated levels can indicate the kidneys aren't working well) high at 30 (Normal Range 6-22), Creatinine (a waste product produced by your body that is filtered out by the kidneys. An elevated level can be a sign of a possible kidney problem.) high at 2.51 (Normal range 0.50-1.40), AST (an elevated level can indicate liver disease) high at 65 (Normal range 0-41), high sensitivity CRP (c-reactive protein high levels can indicate a serious infection) high at greater than 300 (Normal range 0.0-5.0), Lactate (an elevated level can indicate organs are not functioning properly) high at 3.3 (Normal range 0.7-2.1) Procalcitonin (a substance the body produces in response to bacterial infection, elevated levels can indicate a serious infection or sepsis) high at greater than 100 (Normal range less than 0.08).

While in the ED at Facility-B P11 received 5 liters of IV fluid, IV Zosyn (antibiotic), IV Vancomycin (antibiotic) and a Levaquin tablet (antibiotic). P11 was also started on a levophed (an IV medication used to treat low blood pressure ) infusion. P11 was transferred to Facility-C via Advanced Life Support (ALS) ambulance at 8:50PM. Vital signs prior to transfer were T 98.6, P 91, R 30, BP 102/47 MAP 65. Facility -B documented the transferring diagnosis as Septic shock without obvious source.

D. During an interview on 1/3/23 at 1:00PM, MD-A revealed that he does not remember P11 however he was able to review the medical record. MD-A states that looking at the chart P11 looked more viral sick than bacterial sick. P11s lung sounds were clear, and a chest x-ray was not indicated. MD-A felt that with an elevated creatinine and the increase in P11's pulse that P11 was dehydrated. MD-A was asked if P11's blood pressure was concerning, and MD-A replied that the blood pressure could have been due to the dehydration. When asked if MD-A thought P11's lab should have been redrawn due to the EDTA-medicated platelet clumping (an anticoagulant used in blood collection tubes can cause the platelets to clump). MD-A responded that he did not feel that the lab needed to be redrawn. MD-A stated that he worked 3P-12A on 9/8/23 so he was not working when P11 was discharged. MD-A stated that he would have reported off to the oncoming medical provider at the end of his shift, but he does not recall P11 or reporting off.

E. During an Interview on 1/3/23 at 2:30PM, RN-F revealed that in the ED the EMR is set up to run the sepsis screening in the background when criteria information is entered. In the ED the system runs the qSOFA (quick sequential organ failure assessment) screen. Criteria used for screening include altered mental status (AMS), respiratory rate greater than 22 and hypotension (low blood pressure) SBP (systolic blood pressure - the top number of blood pressure) less than 100. RN-F confirmed that since P11 did not have mental status and respiratory rate entered with documented vital signs the qSOFA screen did not run. RN-F stated that expectation for vital signs is hourly. The hourly vital signs expectation is to include temperature and respiratory rate. RN-F stated there was not a policy for vital signs only that they are a care expectation. RN-F confirmed that P11 was not screened by the EMR using the qSOFA screen due to no respirations or the altered mental status being addressed during the ED visit after the initial set of vitals.