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Based on the chart review and interviews, the facility failed to ensure that an appropriate medical screening was performed. The medical screening examination was inappropriate as imaging of the brain and continuous monitoring with pediatric specialist consultation were not obtained in 1 of 1 (pt.#1) patient charts reviewed.

FINDINGS:

A review of the patient #1's medical chart revealed she was a 4-day-old female who was born at this facility. The patient was brought into the Emergency Department (ED) by her mother and father on 9/21/24 at 0243. The triage nurse documented, "Mother states patient had a seizure, patient started 'jerking her arms, dropped her head, and her mouth started moving. Mother also states isn't eating much." The triage nurse documented the patient was alert, awake, active, and playful. Smiles and coos appropriately." Patient #1 was entered as a level 5 ESI.

A review of the chart revealed that the ER Physician #4, MD, saw the patient at 0254. The physician's notes dated 9/21/24 at 0301 stated,

"CHIEF COMPLAINT:
Mother states patient had a_ seizure. patient started "jerking her arms, dropped her head and her mouth started moving. Mother also states patient isn't eating much.

HISTORY OF PRESENT ILLNESS:
The patient is a 4--day-old born full-term without complications. Mom had apparently just fed the baby a few hours ago and shortly after she was holding the baby and the baby started making some funny motions and mom took a video of. In looking at it looks like the child is very awake and alert but has an interesting repetitive head motion and also had a little bit of right-hand twitching. It lasted less than a minute. During that time the child did not seem to lose consciousness or change in color in any way and remained pink and alert. Mom states the child has been feeding although it takes the child a little while to get going. Child's been wetting the diaper not having any vomiting or fevers or difficulty breathing.
Vital signs
Temperature Oral 36 5 degC (09121 02:43)
Heart Rate 127 bpm (09121 02:43)
Respiratory Rate 31 breaths/min (09/21 02:43)
Sp02/Pulse Oximetry 100 % (09/21 02:43)
Dosing BMI 15 (09/21 02:43)
The child is alert and very active, moving all extremities, and appears to be in no distress. Pink both well-perfused and well-hydrated. Anterior fontanelle is open and flat, mucous membranes are moist, there is no nystagmus.

Pupils are reactive and equal. The patient has an excellent suck
Neck is supple without adenopathy
Chest is clear to auscultation
Heart regular rate without murmur
Abdomen is benign soft and nontender in the umbilical stump is clean and dry
GU is normal female
Extremities are without edema
Skin is warm and dry without rash
Neuro: The child moves all extremities equally. Child has a positive Moro and a positive
startle response.

MEDICAL DECISION MAKING:
The video that the mom showed me is a bit concerning as there was some repetitive hand motion is in a little bit of head motion that was repetitive as well. But the child never was altered in any way and did not turn dusky at all and then was completely fine after that So it is difficult to know what to make of this. Especially is an isolated incident and an otherwise well-appearing child with normal vital signs and a completely benign exam with no complications during the birth or pregnancy. 1 very much doubt without any altered mental status that the electrolytes are grossly abnormal and there is been no vomiting or diarrhea or fevers and so I do not think this child has meningitis or encephalitis or head bleed at this time Or any type of perinatal infection. Basic labs were done as a screen all of which were fine x for elevated K from hemolysis. Ca, Na and Glu and WBC all normal and reassuring. I don't think the child needs imaging at this time . Mom was told to contact the pediatrician on Monday for follow-up or to return to the ED if the child continues to have repetitive activities like this as this was just 1 isolated event. Or if there is other new symptoms such as failure to feed at all or persistent vomiting or fevers.

IMPRESSION/PLAN:
Orders:
Primary Assessment
Screenings/History Peds
Triage Pa rt 1
Triage Part 2
Seizure-like activity
DISPOSITION:
home
FOLLOW UP:
No qualifying data available
PCP in 2 days"

A review of the chart revealed the parents were given discharge paperwork on neonatal seizures and discharged on 9/21/24 at 0445.

An interview was conducted with the complainant on 9/30/24 at 10:15 a.m. The complainant was patient #1's grandmother. The Grandmother stated her daughter called her on 9/21/24 and stated the baby was twitching. The Grandmother stated she was a traveling RN and asked the mother to send her the video of the event. The Grandmother stated that she was afraid the baby may be having a seizure and advised her daughter to take the baby to the ER. The baby was seen at the Nacogdoches Medical Center ER and was discharged home with seizure paperwork. The Grandmother stated her daughter was told by the ER physician that it did not look like a seizure to him at this time. The daughter took the patient home. The grandmother stated the baby had another episode at home, and the daughter decided to take her to Longview Regional Medical Center (LRMC) ER. The Grandmother kept stating that Nacogdoches Medical Center would not send LRMC the patient's chart and all the tests had to be reordered. The Grandmother stated the patient was transferred to Children's Hospital in Dallas, Texas on 9/22/24. She stated the baby was in ICU and had just been extubated due to a stroke and brain bleed. She stated the physicians were unsure what happened first the bleed or the stroke. The complainant stated that she wanted to know why physician #4 did not take more precautions or scan the baby if he felt the baby was having seizures. The complainant stated she did not make a complaint to Nacogdoches Medical Center.

A review of the medical record from Good Shepherd Medical Center in Longview, Texas (GSMC) revealed,
"9/21/24 13:40 ED Triage Notes Pt presents to ED. Pt family states yesterday the pt started having small episodes of tightening up and flinching. Pt family states her mouth moves in a funny way during these episodes. Pt family states they last between 30s-1 min, provider shown a video of the episodes. Family states they were seen at Nacogdoches Medical Center around 2am this morning."

A review of the physician notes dated 9/21/2024 1336 stated, " Patient is 4 days old mom is G3, P3 Ab0. Mom brought the child in because she noticed that yesterday and today while feeding she was having some episodes that she describes as a seizure. The patient seemed to be jerking a little bit and mom took a couple of videos of it. Mom says that her pregnancy was unremarkable other than mom had some anemia and she said the delivery was okay except she had a nuchal cord but otherwise was normal she did not have to stay any extra days in the hospital and she had no respiratory problems.
Neurological:
Mental Status: She is alert.
Motor: No abnormal muscle tone.
Comments: No seizure-like activity was observed during the exam.

6:41 PM CDT: Patient presented to the ED with report of possible seizure-like activity we did a workup with blood work I did not witness any seizure-like activity in the ED at this time but the mom has videos that could be confirmatory. I had the on-call pediatrician come down and look at the video and we both agree that this does appear to be abnormal and I think the patient should be transferred to high-level care for further evaluation family agreed with the plan.

The differential for the patient includes, but not limited to new onset seizure electrolyte abnormality
hyperbilirubinemia jaundice
I believe the patient should be transferred to Dallas Children's for evaluation for possible seizure-like activity."

18:35:37 Transfer Disposition
Set up transport to CMC Dallas with Christus EMS. ETA for pick up is 2130 ____ (RN) on 09/21/24 1915.
Noted pt was 89% on RA, RT placed pt on 1L NC. O2 is 95%.
Transferred by ambulance on 09/21/2024 at 2046 to Dallas Children's Hospital.
Called report to Children Medical Center ER on 09/21/24 2057."

An interview was conducted with Staff #1, Director of Nurses at Nacogdoches Medical Center. Staff #1 stated that the facility would accept Neonates back to the NICU for up to 28 days if they were born at the facility. Staff #1 provided the Neonatal Program Plan. On page three, the plan stated, " Infants/neonates up to 28 days after birth with noninfectious clinical conditions may also be admitted to the SCN with Neonatologist and Neonatal Program Manager approval." Staff #1 was asked if this baby could have been admitted for observation to the neonatal unit. Staff #1 stated that if the neonatologist agreed to admit for observation, the designation plan would allow for that. Staff #1 was asked if the physician ER group was aware of this, and she stated she was not sure what type of orientation they received. Staff #3 RN stated that he talks with the physicians when they are new to the ER, but is not aware of any orientation done with the physicians within the facility. There was no orientation in Physician #4's credential file to the hospital.

A phone interview was conducted with Physician #4 on 10/1/24 at 8:32 am. Physician #4 stated he remembered the case and had been informed of the patient's outcome. Physician #4 reported that he was a board-certified ER physician and pediatrician. He reported that when the patient came in, she was very responsive for a newborn, had a flat fontanel, flat no trauma was noted. He reported the baby was sucking and grasping fingers. Blood work was ordered. It all looked good except for a slightly elevated Bili. I watched the video, and there was some mild twitching but no noted postictal state afterwards. I had thought about scanning the baby, but I never saw any signs of seizures or abnormal activity. I talked with the parents and explained that if it happened again, they should come straight back. The patients were to follow up with a pediatrician on Monday for a more extensive workup. Physician #4 reported that he works for a contracted service for ER care at Nacogdoches Medical Center. Physician #4 was asked what type of orientation he had received at the facility. He stated that he had just started at the hospital on 9/17/24 as a locum. Physician #4 reported that the owner of the contracted service was out of the country, but he asked questions from other physicians and staff to orient himself to the facility. Physician #4 reported that he was not aware that the hospital NICU would accept patients back for observation.