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Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to ensure that a diabetic, pediatric patient received an appropriate medical screening examination, including monitoring and reassessment.(A-2406)

Based on document review and interview, it was determined that for 1 of 1 (Pt #1) pediatric, diabetic patient who presented to the Emergency Department (ED) for elevated blood sugar, the hospital failed to ensure that the patient received an appropriate medical screening examination, including monitoring and reassessment.

Hospital A = John H Stroger Jr Hospital
Hospital B = outside hospital where Pt #1 presented same day after discharge from Hospital A

Findings include:

1. The hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", dated 3/22/24, was reviewed, and required, " ...When an EMTALA obligation exists, an appropriate medical screening examination, within the capabilities of the hospital's emergency department ...shall be performed to determine whether an emergency medical condition exists ...Once medical screening is complete and does not reveal an emergency medical condition ...the patient is treated and: 1. discharged when, within reasonable clinical confidence, the patient has reached the point where her/his continued care can be reasonably performed later as an inpatient or on an outpatient basis ...and the patient is given a plan for appropriate follow up care; or admitted as inpatient for continued care; or transferred for continued care ..."

2. The hospital's "Pediatric EM Manual: Guideline for the Management of New Onset Diabetes and Diabetes Ketoacidosis" (undated), was reviewed, and included, " ...For patient who are fully hydrated and well-appearing, the initial work up only needs to include: Glucose and Bicarbonate or glucose and a pH from a Venous Blood Gas (VBG) or an Arterial Blood Gas (ABG); Urine Ketones ...Definition: Diabetic ketoacidosis (DKA) consists of: Significant acidosis (arterial and venous pH <7.30); Hyperglycemia (serum glucose >200); Bicarbonate [less than or equal to] 15 mEq/L [milliequivalents/per liter] and significant ketosis (moderate to large urinary ketones) ...The endocrinologist on call is to be called with all lab test results."

3. The clinical record for Pt #1 was reviewed on 11/12/2024. Pt #1 was a pediatric patient who presented to Hospital A's Emergency Department (ED) on 7/26/2024 at 10:03 PM. Pt #1 was discharged home from Hospital A's ED on 7/27/2024 at 1:25 AM.

- The ED Triage Note (dated 7/26/2024 at 10:22 PM), documented by the Triage RN (E #6/registered nurse), included, "Primary Chief Complaint: Hyperglycemia [high blood sugar]. Pt with PMHx [past medical history] of T1DM [type I diabetes] with c/o [complaints of] hyperglycemia. [Pt #1's parent/Z #2] states pts glucose was 495 [high blood sugar - normal range is 70-100] at [7:30 PM/approximately 3 hours prior to arrival] so [Z #2] gave 20 units of Humalog. [Z#2] reports [Pt #1] has been out of Lantus [long-acting insulin] for the past 'few days'. Pt endorses feeling tired, denies any other complaints ...Acuity 3 [patient requires two or more different resources/ranges from 1-5, with 1 being the most critical]."

- Pt #1's ED Note (dated 7/26/2024 at 11:47 PM), documented by the ED Resident (MD #3), included, " ...History of Present Illness: 15-year old male w/hx type 1 DM c/b [complicated by] hospitalization for DKA [diabetic ketoacidosis/life threatening complication of diabetes] (2022) on insulin presenting from home as a referral by pediatric endocrinologist [Z #1] due to hyperglycemia w/concern for DKA ...Over the past week, notes patient's glucose was in the high 400's, after which [Z #2] gave 25 units Humalog just prior to arrival. Also noted that [Pt #1] had ketones per meter at home. Has observed [Pt #1] appearing generally tired which is consistent with prior episode of DKA. [Pt #1] reports [Pt #1] feels general fatigue ...Ddx [differential diagnosis]: Suspect hyperglycemia in setting of inadequate glucose control at home given off home Lantus X4 days ...Plan: IVF [intravenous fluids], refill home meds. Labs. Endocrine clinic referral placed. Re-evaluation: CMP [complete metabolic panel lab] elevated glucose 268 ...UA [urinalysis] with glucosuria [sugar in urine] and ketonuria [ketones in urine]. VBG [venous blood gas] elevated lactate [determines if oxygenation is impaired] 2.3 otherwise no acidosis concerning for acute DKA. Dispo[sition]: Possible home with outpatient follow-up pending clinical improvement and with refills of home medication."

- Pt #1's documented blood glucose levels were reviewed. One bedside glucose reading was recorded on 7/26/2024 at 10:22 AM (in triage). The result was 298 (high level - normal range 70-100). There were no subsequent blood glucose readings documented.

-Pt #1's orders were reviewed and included the following labs ordered and resulted:
7/26/24 at 10:21 PM: Basic Metabolic Profile; Lipase Level: Liver Enzymes; Urinalysis; Liver Profile; CBC with Differential; Blood Gas, Chemistry, Lactate, HgBs Venous; HBG A1c; and an ED CMP. The blood work results included: an elevated serum glucose (268/normal range 90-130) and an elevated lactate level (2.3/normal less than 2 millimole/per Liter). The urinalysis results included glucose >1000 (normal should not be detectable in urine) and high ketones 100 millimoles per liter (normal range is less than 0.6 millimoles per liter). Pt #1's lab results included a moderate to large amount of ketones and a serum glucose greater than 200. The clinical record lacked notification to the endocrinologist on-call or to Pt #1's endocrinologist (Z #1).

-Pt #1's orders also included sodium chloride 0.9 % 1 Liter bolus intravenous fluids that was initiated on 7/26/2024 at 10:34 PM and completed on 7/26/2024 at 11:37 PM.
There were no further orders for Pt #1 during this ED encounter, including any orders for insulin; additional labs; or additional/recheck of bedside glucose.

- An ED Note (dated 7/27/2024 at 12:14 AM), documented by the ED Resident (MD #2), included, " ...Subjective: At time of sign out, states that feels well, would like food. Family at bedside asking when they may leave ...Assessment and plan: hyperglycemia. No evidence dka. Medications sent to pharmacy. Fu [follow-up] endocrine. After reviewing the patient's history, physical and medical work-up I believe they are safe for discharge home at this time ..."

- The ED Nursing Discharge Note (dated 7/27/2024 at 1:19 AM), documented by a ED RN (E #8), included, "[Z #2] was given discharge instructions. Advised to return to ED with new or worsening symptoms. Pt and parent verbalized understanding with no further questions."
Pt #1 received home prescriptions at discharge for insulin (Lantus and Humalog) and blood glucose monitoring supplies. A follow-up appointment with Pt #1's endocrinologist (Z #1), was scheduled for 9/4/2024.

4. On 11/15/2024, the clinical record from Hospital B was reviewed. The record included that Pt #1 presented to Hospital B's emergency department on 7/27/2024 at 8:37 PM. The ED physician's history and physical included, "[Pt #1] with known diagnosis diabetes mellitus who presents with hyperglycemia and ketosis x 2[days]. Events leading to presentation at ED: Per MOC [mother of child], she has had difficulty obtaining patient's long acting insulin due to just recently obtaining insurance. Has not had the long acting version for about four days. Yesterday, patient was feeling nauseous and complaining of abdominal pain, had NBNB [non-bloody, non-bilious] emesis. Was seen at ASH [outside hospital], where they gave fluids and said he was "ok to go home." MOC reports that today AM patient had glucose of 116 so she did not give his insulin. [Pt #1] reported no appetite and ongoing nausea, so no additional insulin was given throughout the day. This evening, had another episode of emesis at which time MOC became concerned for DKA and called 911. EMS [emergency medical services] checked BG [blood glucose] and found to be in 400s ... In triage mental status was noted to be appropriate. Initial POC glucose was 590 ... Assessment/Plan: On evaluation, found to have dry mucous membranes, tachycardia, normal mentation. Labs notable for pH 7.1 bicarb 8, BG 559, HgA1c 14.3 [average blood sugar levels over the past 2-3 months -normal below 5.7%], elevated BHB [level of ketones in blood] and ketones on urine dip - most consistent with DKA. Endocrinology consultation obtained and admission recommended for additional management ... Plan: labs and fluids ... start insulin drip, admit to endocrinology, continue to monitor neurologic status, consider SW [social worker] consultation for family support." The record indicated that consultation with endocrine services was completed in the ED; Pt #1 was administered medication for nausea; was started on an insulin drip; hourly glucose checks and neuro checks and additional labs were ordered; and Pt #1 was admitted to Hospital B on 7/27/2024 at 10:54 PM.

5. On 11/13/2024 at 9:10 AM, a telephone interview was conducted with an ED Resident (MD #2). MD #2 stated that Pt #1 was signed out to MD #2 on the night shift of 7/26/2024. MD #2 stated that Pt #1 was sent to the ED by Pt #1's endocrinologist (Z#1) with concerns for DKA. MD #2 stated that MD #2 reviewed Pt #1's labs and consultation notes. MD #2 stated that it was noted that Pt #1 had ketones in the urine; had glucose in the urine; and the blood work showed that the anion gap was high due to Pt #1 being a poorly controlled diabetic. MD #2 stated that a blood sugar of 298 is high, however, MD #2 felt good about discharging Pt #1 since Pt #1's labs showed that Pt #1 was not in DKA, and the Pt #1 was wanting food. MD #2 stated that a patient wanting food would not be the presentation of a patient with DKA.

6. On 11/13/2024 at 9:40 AM, an interview was conducted with ED Resident (MD #3). MD #3 stated that MD #3 performed Pt #1's MSE (medical screening exam) when Pt #1 presented. MD #3 stated that Pt #1 presented with concerns for possible DKA. MD #3 stated that there were concerns with Pt #1 getting home insulin. MD #3 stated that Pt #1's parent (Z #2), did give short acting insulin prior to coming (approximately 2-3 hours before) due to the blood sugar being in the 400's. MD #3 stated that type of insulin peaks in about 1-2 hours. MD #3 stated that when Pt #1 presented, Pt #1 looked generally tired and was hyperglycemic with a blood sugar over 200. MD #3 stated that there is a "Care Set" in the computer on how to manage hyperglycemia including giving IV fluids and insulin. MD #3 stated that the "Care Set" is an algorithm that determines the amount of insulin to give, based on the patient's home regimen and the current blood sugar. MD #3 stated that after reviewing Pt #1's labs, Pt #1 did have some factors for DKA, but there was not acidosis, and the pH was normal. MD #3 stated that if a patient's blood sugar is high coming in, the patient's blood sugar should be reassessed after the IV fluid bolus and insulin is given. MD #3 stated that a venous blood gas or blood chemistry would also be repeated in about 3-4 hours. MD #3 stated that this way, we (doctors) would be able to determine if the treatment was effective and if we (doctors) still need to monitor the patient.

7. On 11/13/2024 at 10:00 AM, an interview was conducted with the ED Triage RN (E #6). E #6 stated that Pt #1 was a Type 1 Diabetic who came in due to being out of long-acting insulin. E #6 stated that when Pt #1 came in, an accucheck (point of care/bedside glucose testing) was done and the blood sugar was 298. E #6 stated that a line (IV) was started on Pt #1 and the patient received a bolus of IV fluids and labs were drawn. E #6 stated that it is up to the doctor's discretion if they want to give insulin. E #6 stated that if the initial blood sugar is high, it should be rechecked after 2 hours.

8. On 11/13/2024 at12:05 PM, an interview was conducted with the ED Pediatric Division Chair (MD #4). MD #4 stated that Z #1 sent Pt #1 to the ED with concerns about DKA. MD #4 stated that the patient came in needing a medical screening exam and received one. MD #4 stated that Pt #1's (parent/Z #2), gave Pt #1 the short acting insulin (Humalog) as a pre-treatment prior to coming to the ED. MD #4 stated that when Pt #1 presented, orders included getting a point of care glucose; a urinalysis; a blood gas; and a bolus (IV fluids). MD #4 stated that the blood glucose was from 280-289 and the blood gas showed that Pt #1's pH was normal. MD #4 stated that Pt #1's bicarbonate level was normal. MD #4 stated that since Pt #1 was not in DKA, the goal should have been to ensure that the patient was back on the long-acting insulin for stability. MD #4 stated at that time of night (around midnight), when the patient was discharged, the means to get the prescription for the Lantus could have been difficult. MD #4 stated that Pt #1 could have received the Lantus while in the ED or even been admitted. MD #4 stated they (ED physicians) could have monitored the ketones more closely by getting a repeat urinalysis, prior to discharging Pt #1. MD #4 stated that also another blood sugar could have been checked to get more data. MD #4 stated that communication is key and that the ED physicians should have consulted with Pt #1's endocrinologist.

9. On 11/13/2024 at 2:35 PM, an interview was conducted with Pt #1's Endocrinologist (Z #1 - from outpatient clinic associated with hospital). Z#1 stated that Z #1 received a call from Z #2 stating that Pt #1 was out of Lantus. Z #1 stated that also Pt #1's blood sugar was high and had large ketones at home. Z #1 stated that Z #1 advised Z #2 to take Pt #1 to the ED to get evaluated and to rule out DKA. Z #1 stated that Z #1 is aware that Pt #1 did come to Hospital A's ED and was discharged home. Z #1 stated that Z #1 called Z #2 to follow up and found out that Pt #1 was being admitted to Hospital B for DKA (according to Z #2). Z #1 stated that, regarding Pt #1's care in Hospital A's ED, Z #1 would have ordered, if was consulted, Pt #1 to receive the Lantus. Z #1 stated that Z #1 would have also ensured that the ketones were clearing/going down. Z #1 stated that if there is acid build up in the body, the patient could become nauseous, have vomiting, dehydration, effect on the brain, and even become comatose.