HospitalInspections.org

HL29F


Based on records review and staff interviews, the hospital failed to have policies and procedures in place to ensure that all patients who presented to the emergency department (ED) received adequate medical screening examination and stabilizing treatment for an emergency medical condition in compliance with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA).

Twenty five (25) medical records were randomly selected from the ED log from March 2014 to August 2014.

The hospital failed to provide adequate medical screening examination to patients # 22, #7, and #20.

The hospital failed to provide stabilizing treatment within its capabilities to patient # 20, who presented three times with an emergency medical condition.

The hospital ED sees on average 849 patients per month and transfers on average 55 patients per month from March to August 2014.

1. In an interview on 8/26/14, at 11:35 AM, the Acting Director of Nursing stated that the hospital did not have any written and approved policies and procedures to implement the requirements of EMTALA such as the provision of an appropriate medical screening examination to any individuals presenting for an examination of a medical condition, provision of stabilizing treatment within the hospital's capabilities, and appropriate transfers of any individuals with emergency medical condition to another hospital in compliance with the transfer requirements specified under the EMTALA regulations.

The Acting Director of Nursing said the hospital did not have EMTALA policies and procedures because "Staff in the ED have been trained and tested on EMTALA and they follow the law."

The Acting Director of Nursing said "All our policies and procedures are hospital-wide, and we are currently revising them." The Acting Director of Nursing stated that the nursing policies are derived from a nursing text book and that a copy of the text book is kept in the locked Pyxis medication dispensing machine located in a locked room in the ED.

On 8/27/14, the last day of the survey the Acting Director of Nursing provided the surveyor with copies of two policies titled "EMTALA Policy" and "ED Patient Transfer to Higher Level of Care Policy & Procedure" with an approval date of 8/27/14. At the time of approval, ED staff had not yet received training on the two policies.

The policy titled "EMTALA Policy", page 6 of 21, under Section V. Medical Screening Examination in the Emergency Department, limited who may provide the medical screening examination (MSE) to "physicians" with appropriate clinical privileges and "resident physicians."

Further, on page 8 of 21, under Section VI, "Examination of Pregnant Women with Contractions" the policy specified that a "physician" with appropriate privileges or a "resident physician" may provide the MSE.

The policy was inconsistent with the Medical Staff Bylaws, Rules & Regulations 2011 - 2013, page 11 of 60, which expanded the medical professional capable of providing the MSE in the emergency department to include licensed independent practitioners defined as MDs, DOs, Nurse Practitioners, Physician Assistants, Nurse Midwives, or Dentists.

Another inconsistency noted was the reference to an "obstetrics nurse" responsible for documenting the physician's determination that a pregnant woman did not have an emergency medical condition, page 10 of 21 of the Medical Staff Bylaws, Rules & Regulations .

However, the second EMTALA policy titled "ED Patient Transfer to Higher Level of Care Policy & Procedure" specified, page 3 of 7, that the hospital did not have an obstetrical labor and delivery unit. Further, the transfer policy, page 3 of 7, specified that a "physician" completes the MSE.

Neither policy (EMTALA Policy or the ED Patient Transfer policy) specified a process for ensuring that a physician performed the MSE when a non-physician practitioner was scheduled to work in the ED or when the condition of the individual is such that it requires the knowledge and expertise of a physician, specified that non-physician practitioners (in addition to physicians and resident physician) may provide the MSE as indicated in the Medical Staff Bylaws.

HL29F


Based on records review and staff interviews, the hospital failed to provide an appropriate medical screening examination to three patients (patients # 22, #7, #20) out of 25 medical records reviewed from March 2014 - August 2014.

Based on the interviews and records review, it was determined that the failure of the hospital to provided appropriate medical screening examination to individuals presenting to the Emergency Department of the hospital seeking examination of a medical condition had caused actual harm and is likely to cause harm to all individuals that come to the hospital for examination and/or treatment of a medical condition. These failures are determined to present an Immediate Jeopardy to the health and safety of all individuals served by the hospital.


1. Review of the medical record showed Patient # 22, a 20 year old male, presented to the ED on 8/3/14, at 10:09 PM, complaining of sinus pressure, sore throat, and pressure in his ears since 7/26/14.

At 10:25 PM, ED nurse A triaged patient # 22 as non-urgent and documented his blood pressure was 139/98 (normal 120/80), the weight was 344 pounds and the pain a level was 5 on a scale of 1 - 10 (10 most severe).

At 10:30 PM, physician assistant (PA) # 1 documented that the patient had high functioning autism, and that he denied fever, weight loss, or chills, shortness of breath, difficulty breathing lying flat, swelling or wheezing.

Further review of the medical record showed PA # 1 examined patient # 22 and documented his ear drums were red and that the patient had mucopurulent (mucus and pus) drainage in his throat.

PA # 1 documented the patient had left lower lobe (of the lung) "consolidation to tactile fremitus" (feeling for vibrations on the patient's chest while they repeatedly say "99", the vibrations generated by a solid mass feels different than vibrations generated by fluid) and percussion (listening for resonant or dull sounds when tapping your fingertip on the patient's chest).

PA # 1 diagnosed patient # 22 with pneumonia, left lower lobe, and acute suppurative otitis media (meaning a perforated eardrum with drainage from the middle ear) without spontaneous rupture of the eardrum. PA # 1 prescribed an antibiotic (Zithromax Z-Pak), Albuterol inhaler (inhaled medication that relaxes muscles in the airways to increase air flow) and Ibuprofen.

At 10:34 PM (9 minutes after triage), ED nurse A provided the patient with a discharge instructions handout specific to pneumonia and ear infections.

At 10:45 PM, patient # 22 departed the ED. The medical record did not contain evidence that patient # 22 received an examination sufficient to determine whether an emergency medical condition existed (including laboratory tests or a chest x-ray to determine the presence or absence of pneumonia).

In an interview on 8/26/14, at 10:35 AM, the ED nursing supervisor confirmed that the radiology department has an x-ray technician on-call by cell phone 24 hours a day, 7 days a week.

The ED nursing supervisor also confirmed that the lab has a technician on-call by cell phone 24 hours a day, 7 days a week and that the ED nurses are able to draw blood and perform limited lab tests such as a complete blood count (several components of the patient ' s blood are measured and abnormal decreases or increases may indicate underlying medical condition requiring further evaluation) in the ED.

In an interview on 8/27/14, at 12:45 PM, the Acting Clinical Director stated that PA # 1 was contracted staff who was not currently working at the hospital. The Acting Clinical Director stated that the hospital had recently revised the contract for the mid-level practitioners (practitioner other than a physician) because it had not previously specified ED or outpatient experience. As we result, "we got mid-levels without ED experience."

In an interview on 8/29/14, at 12:22 PM, patient # 22's father stated that he accompanied his son to the ED on 8/3/14, and stayed at his bedside. The father stated that on 8/3/14, his son complained of a severe headache and ringing and pressure in his ears. The father stated that the doctor made his son say the number "99" repeatedly while listening to his lungs. "The doctor said my son had walking pneumonia." "I asked about a chest x-ray but the doctor said he didn't need one to diagnose walking pneumonia." The father stated his son's blood pressure was high, that he complained his throat was bothering him and was nervous. The father stated the doctor did not feel his son's neck to check for swelling. The father stated the doctor checked only one of his son's ears and said he had an infection and later in the exam, could not remember which ear he had checked. The father said he repeatedly asked the doctor to check both ears. The father stated the doctor prescribed his son an antibiotic and another medication.

Review of a second medical record of patient # 22 revealed that he returned to the ED on 8/5/14, at 7:24 PM (less than 48 hours after discharge on 8/3/14). He complained of nausea since midnight, one loose bowel movement and a headache when coughing.

ED nurse B triaged the patient as non-urgent and documented the patient's blood pressure was 147/76 and he rated his headache pain a 7. "All exam rooms full at this time", patient "asked to return to waiting area"; patient taken back to ED exam room at 8:35 PM, without any change in his acuity. Further documentation showed that patient # 22 was provided with "discharge instructions per MD (medical doctor)." At 10:05 PM, the patient left the ED. The medical record did not contain evidence that the patient received an examination from the on duty ED physician # 2 as required.

Review of the ED physician schedule showed that on 8/5/14, ED physician # 2 was on duty for the night shift (8:00 PM - 8:00 AM).

During an interview on 8/27/14, at 12:45 PM, the Clinical Director stated that ED physician # 2 was a contracted physician "who no longer works at the hospital." The Clinical Director confirmed that ED physician # 2 did not document anything in patient # 22's 8/5/14 medical record.

Review of the Medical Staff Bylaws, Rules and Regulations (page 57 of 60) # 2 "Emergency Room services:"

b. "All patients presenting to the ER or clinic will receive a medical screening exam."

c. "MD's, PA's, and CNP's may complete a medical screening exam."

d. "The emergency room record shall be complete with history, physical, diagnosis, treatment and patient instructions, condition on discharge, follow up and disposition of the case."

e. "Transfers from the hospital and the ER shall be in compliance with all COBRA/EMTALA regulations and hospital Standards of Practice concerning transfers. All transfers must be signed by a physician."

In an interview on 8/29/14, at 12:22 PM, patient # 22's father stated that he accompanied his son when they returned to the ED on 8/5/14 and stayed at his bedside. The father said his son complained of a pounding headache and a really dry mouth, "I knew he was really sick." The father stated that a different doctor was on duty and asked them why they came to the ED for a dry mouth? "The doctor listened to my son's lungs and said he didn't have pneumonia." "I told him what the other doctor prescribed and he said kind of surprised, "You got a Z-pak for pneumonia?" "Then, the doctor looked in my son's ears and said he had an ear infection and that the Z-pak wouldn't help so he changed the antibiotic to penicillin. The father confirmed that no x-rays or laboratory testing was performed.

Review of a third medical record of patient # 22 revealed that he returned to the ED on 8/6/14 at 8:57 PM (less than 24 hours after discharge on 8/5/14). He complained of feeling anxious, nausea and "vomits water" and complained of headache due to sinus pressure. PA # 1 diagnosed patient # 22 with hyperglycemia (high blood glucose) with probable DKA (diabetic ketoacidosis, an emergency medical condition) and at 11:55 PM, arranged a transfer to Hospital B using an ambulance with basic life support capabilities. Refer to Tag A2409 for further details.

Review of a fourth medical record of patient # 22 revealed that he presented to the ED on 8/27/14, at 9:25 AM. He complained of pain to his mid-back since 8/26/14 and described the pain as sharp. At 10:10 AM, ED physician # 5 examined patient # 22 and documented that the patient's active problems included Autism, Obesity, and Diabetes Type I Uncontrolled.

Further documentation revealed that patient # 22 complained of low back pain since last night, rated his pain a 9 out of 10 in intensity, complained that it was constant, alleviated by immobilization and worsened by some positional changes. ED physician # 5 documented "There were no accidents or traumas previous to onset of pain." Review of the medication list in the medical record showed that patient # 22 had been prescribed fast acting insulin (Insulin Aspart) by injection three times daily, and long acting insulin (Insulin Detemir) twice daily on 8/22/14.

Documentation by ED nurse D showed that the patient received an intramuscular injection of Ketorolac 60 mg (medication used for short-term relief of moderately severe pain) at 8:45 AM on 8/27/14, which was inconsistent with the time (approximately one hour prior) patient # 22 presented to the ED.

At 10:55 AM, patient # 22 departed the ED with instructions to limit his activity, exercise at home, and follow adequate diet and maintain control of his diabetes. The medical record did not contain evidence that the ED staff performed a medical screening examination sufficient to determine whether an emergency medical condition existed including re-assessing patient # 22's level of pain, performing any imaging studies to determine the origin of the patient's back pain or conducting laboratory testing of his blood glucose level to determine if it was within normal limits.

In an interview on 8/29/14, at 12:22 PM, patient # 22's father stated he accompanied his son to the ED on 8/27/14 and stayed at his bedside. The father stated he was concerned that his son's back pain was somehow related to his diabetes and that he asked for an x-ray but the doctor declined. The father also stated that no one asked his son about his blood glucose levels or checked his blood sugar.


The hospital failed to provide appropriate medical screening in that the condition of the patient required the knowledge and expertise of a physician but only a midlevel practitioner examined the individual.


2. Review of the medical record of patient # 7, a 53 year old male, revealed that he was brought to the ED by ambulance on 6/10/14, at 7:50 AM. Documentation revealed that patient # 7 was unresponsive and had a history of renal dialysis, chronic obstructive pulmonary disease (COPD), diabetes, stroke, coronary artery disease, congestive heart failure and obesity.

At 8:00 AM, ED physician # 6 examined the patient. The patient's initial oxygen saturation level was 99% (normal 95 - 100%) and documentation revealed that he was placed on 6 liters of oxygen by a non-rebreather mask (delivers high concentration of oxygen, which may cause carbon dioxide retention in a patient with COPD, leading to respiratory collapse). Further documentation revealed that a Foley catheter was inserted into the bladder to drain urine and a diagnostic 12 lead EKG was obtained at 8:10 AM. The EKG showed abnormalities indicative of a possible heart attack or severe hyperkalemia (critically high potassium level).

At 8:13 AM, blood was obtained for laboratory testing including a cardiac profile, a complete blood count (several components of the patient's blood are measured and abnormal decreases or increases may indicate an underlying medical condition requiring further evaluation) and a comprehensive metabolic profile (group of blood tests that measure the sugar level, electrolyte and fluid balance, and kidney and liver function).

At 8:15 AM, ED physician # 6 contacted the physician at Hospital B to arrange a transfer. Further documentation revealed that cardiac monitoring began at 8:30 AM, nearly 40 minutes after patient # 7 arrived in the ED. ED physician # 6 documented that patient # 7 was due for his dialysis treatment" today" and that "unfortunately the patient was not given an Aspirin or Lovenox (blood thinning medication commonly given in the ED to heart attack patients) before his transfer to Hospital B due to lack of data and late arrival of lab results."

Review of the lab report showed that results were entered in the medical record at 8:45 AM, 10 minutes after patient # 7 was transferred to Hospital B. The lab report showed the patient's potassium level was elevated at 9.47 (normal 3.6 - 5.0, a critically elevated potassium may result in sudden death from cardiac arrhythmias).

The hospital failed to provide appropriate medical screening examination to Patient #7 to address the presenting symptomatologies and abnormal results of diagnostic testings.


3. Review of the medical record of patient # 20, a 5 year old, who was brought to the ED by ambulance at 7:07 PM on August 15, 2014, accompanied by his mother. ED nurse A triaged the patient as "urgent" and documented that the patient presented with "dehydration." The mother stated that patient # 20 had one wet diaper on that day and a bowel movement on 8/14/14.

Patient # 20's past medical history included tuberous sclerosis (rare genetic disorder that causes seizure disorders, developmental delay, intellectual disability and autism) and gastroschisis (rare condition in which the stomach and bowel are formed on the outside of the fetus' belly requiring surgical repair).

Further documentation revealed that patient # 20 appeared "very pale, thin and frail and is non-verbal," weighed 29 pounds and had a rapid heart rate of 136 (normal is 80-120). At 8:00 PM, ED physician # 7 examined patient # 20 and documented that the mother brought patient # 20 to the ED because he did not have any oral "intake whatsoever today."

Further documentation revealed that patient # 20 had epilepsy, a history of recurrent pneumonia, developmental delays and was very fussy, "crying almost constantly." At 8:18 PM, ED physician # 7 ordered laboratory testing that included a complete blood count (several components of the patient's blood are measured and abnormal decreases or increases may indicate underlying medical condition requiring further evaluation) and a comprehensive metabolic profile (group of blood tests that measure the sugar level, electrolyte and fluid balance, and kidney and liver function).

Review of the 8/15/14, at 8:27 PM, radiology report (abdominal x-ray) showed "considerable formed stool in the colon, including the right colon and in the rectum."

ED physician # 7 documented, untimed, serial vital signs under the section of the medical record titled "OBJECTIVE: EXAM AND OBJECTIVE DATA" which showed that patient # 20 had a rapid heart rate (136 - 156 beats per minute) and fluctuating BPs (98/65 - 143/81). ED physician # 7 diagnosed patient # 20 with obstipation (intestinal obstruction) and dehydration. ED physician #7 discharged the patient at 00:25 AM on 8/16/14.

Review of the clinical laboratory report showed unreliable results, specifically the time noted for blood collection was 6:40 PM on 8/15/14, one hour before patient # 20 presented to the ED. The results of the testing were documented in the medical record at 8:47 AM on 8/16/14, nearly nine hours after patient # 20 was discharged. The lab report showed the patient had an abnormal high blood glucose level (171 milligrams/deciliter, normal 65 - 100) and an abnormal high white blood cell count 13.3 K/cmm3 (normal 4 - 11 K/cmm3).

Review of a second medical record of patient # 20 revealed that he was brought back to the ED on 8/17/14, at 3:36 AM, about 24 hours after discharge complaining of vomiting and constipation.


ED nurse B triaged the patient as urgent. At 4:05 AM, ED physician # 7 examined patient # 20 and documented that he had chronic constipation with known bowel obstruction in the past; mom stated that he has been vomiting everything she gives him since 9:00 AM and that he vomited up all his medication that day too.


Further documentation revealed that patient # 20's home medications included Senna (laxative), Miralax, Tegretol (anti-seizure medication), Clonazepam (anti-seizure medication) and one other medication.


At 5:50 AM, patient # 20 was transported to radiology for an abdominal x-ray. The radiology report showed that patient # 20 had "considerable stool in the colon, the rectum is filled with solid stool." "Dilated small bowel persists consistent with mechanical small bowel obstruction."


Review of the clinical laboratory report showed unreliable results, specifically the time noted for blood collection for some lab tests was 8/17/14 around 4:41 AM and the blood collection for other lab tests was dated 8/19/14 at 4:06 PM, over 48 hours after patient # 20 was discharged. The results of all the 8/17/14 lab testing were not entered into the medical record until 8/19/14 at 4:06 PM. The lab report showed the patient had an abnormal high white blood cell count of 15.2 K/cmm3 (an increase from 8/15/14) and a low potassium level of 3.3 millimoles/Liter (normal 3.6 - 5.0 mmol/Liter, low potassium can cause life threatening changes in the heart rhythm).


Additionally, ED physician # 7 did not order a blood test to measure patient # 20's anti-seizure medication (Tegretol) levels to determine whether they were normal in light of his vomiting and dehydration on 8/15/14 nor on the second ED visit on 8/17/14, or repeat the potassium level to monitor for further changes following the fluid boluses.

Review of a third medical record of patient # 20 revealed that he was brought back to the ED on 8/18/14, at 5:21 PM, approximately 32 hours after discharge on 8/17/14. ED nurse F documented patient # 20's parent stated "this is the third time we have brought him in, they keep sending us home."

At 6:06 PM, ED nurse F attempted to start an IV but was unsuccessful. ED physician # 8 examined patient # 20 and documented that the patient was listless, had a weak cry, almost limp, dazed gaze, sunken eyes, had shallow respirations, a rapid heart rate, very distended abdomen, and was severely dehydrated and had intractable vomiting and required an IV bolus and "immediate transfer."

The hospital failed tof provide appropriate medical screening examination to address the presenting symtomatologies and abnormal results of diagnostic tests performed.

HL29F


Based on records review and staff interviews, the hospital failed to provide appropriate stabilizing treatment withn the hospital's capability to one individual (Patient # 20) who presented to the emergency department three times seeking care for an emergency medical condition, out of 25 medical records reviewed from March 2014 - August 2014.


Based on the interviews and records review, it was determined that the failure of the hospital to provide appropriate stabilizing treatment within the capacity and capability of the hospital had caused actual harm and is likely to cause harm to all individuals that come to the hospital for examination and/or treatment of a medical condition. These failures are determined to present an Immediate Jeopardy to the health and safety of all individuals served by the hospital.




1. Review of the medical record of patient # 20, a 5 year old, who was brought to the ED by ambulance at 7:07 PM on August 15, 2014, accompanied by his mother. ED nurse A triaged the patient as "urgent" and documented that the patient presented with "dehydration." The mother stated that patient # 20 had one wet diaper on that day and a bowel movement on 8/14/14.

Patient # 20's past medical history included tuberous sclerosis (rare genetic disorder that causes seizure disorders, developmental delay, intellectual disability and autism) and gastroschisis (rare condition in which the stomach and bowel are formed on the outside of the fetus' belly requiring surgical repair).

Further documentation revealed that patient # 20 appeared "very pale, thin and frail and is non-verbal," weighed 29 pounds and had a rapid heart rate of 136 (normal is 80-120). At 8:00 PM, ED physician # 7 examined patient # 20 and documented that the mother brought patient # 20 to the ED because he did not have any oral "intake whatsoever today."

Further documentation revealed that patient # 20 had epilepsy, a history of recurrent pneumonia, developmental delays and was very fussy, "crying almost constantly." At 8:18 PM, ED physician # 7 ordered laboratory testing that included a complete blood count (several components of the patient's blood are measured and abnormal decreases or increases may indicate underlying medical condition requiring further evaluation) and a comprehensive metabolic profile (group of blood tests that measure the sugar level, electrolyte and fluid balance, and kidney and liver function).

Review of the 8/15/14, at 8:27 PM, radiology report (abdominal x-ray) showed "considerable formed stool in the colon, including the right colon and in the rectum."

ED nurse A obtained blood for laboratory testing at 8:55 PM.

At 9:05 PM, ED nurse A administered the first intravenous (IV) fluid bolus (medicine given all at once) in the amount of 270 milliliters (ml) (270 ml = 9.12 ounces).

At 9:25 PM, ED nurse A documented the IV fluids had infused and that patient # 20 "still does not have tears, hasn't urinated and mucous membranes are still dry." Further documentation showed that ED physician # 7 ordered a second IV fluid bolus of 270 ml which was completed at 9:45 PM.

At 9:53 PM, ED nurse A administered ½ of a Dulcolax suppository and at 10:30 PM, the patient passed a small amount of liquid stool.

At 10:08 PM, ED nurse A administered the third bolus (270 ml) of IV fluids which was completed at 10:28 PM. ED nurse A documented patient # 20 was crying but still did not have tears and had not wet his diaper.

At 11:00 PM, ED nurse A administered ½ of a Fleets enema and at 11:10 PM, patient # 20 passed 2 formed stools.

At 11:15 PM, ED nurse A administered the fourth IV fluid bolus of 190 ml (6.4 ounces), "totaled infused, all boluses 1,000 ml " (one liter). ED nurse A documented "Patient now has tears when he cries and has had one wet diaper here in ER tonite."

At 11:30 PM, ED nurse A documented patient # 20 vomited a "scant amount" of green bile and at 11:35 PM, administered an anti-nausea medication IV.

At 11:40 PM, patient # 20 received a second 1/2 dose of a Dulcolax suppository and at 11:45 PM passed a large firm stool.

ED physician # 7 documented, untimed, serial vital signs under the section of the medical record titled "OBJECTIVE: EXAM AND OBJECTIVE DATA" which showed that patient # 20 had a rapid heart rate (136 - 156 beats per minute) and fluctuating BPs (98/65 - 143/81). ED physician # 7 diagnosed patient # 20 with obstipation (intestinal obstruction) and dehydration. ED physician #7 discharged the patient at 00:25 AM on 8/16/14.

The medical record did not contain evidence that patient # 20's emergency medical condition was stabilized at the time of discharge. Serial vital signs revealed that patient # 20's heart rate and blood pressure remained unstable and ED physician # 7 did not document a review or interpretation of the laboratory tests that were performed.

Review of the clinical laboratory report showed unreliable results, specifically the time noted for blood collection was 6:40 PM on 8/15/14, one hour before patient # 20 presented to the ED. The results of the testing were documented in the medical record at 8:47 AM on 8/16/14, nearly nine hours after patient # 20 was discharged. The lab report showed the patient had an abnormal high blood glucose level (171 milligrams/deciliter, normal 65 - 100) and an abnormal high white blood cell count 13.3 K/cmm3 (normal 4 - 11 K/cmm3).

In an interview on 9/4/14, at 1:50 PM, patient # 20's mother stated that she brought her son to the ED on 8/15/14, because he kept throwing up. The mother stated the nurse gave her son two enemas and two suppositories. "My son also had an x-ray that showed he was full of poop." The mother stated that the nurse drew blood for lab testing but no one talked with her about the results.

The mother stated that she brought her son back to the ED on 8/17/14, because he continued to throw up. She said that her son received an enema and a suppository and that blood was drawn but "no one told me about what the tests showed." "I was told to keep my son on clear liquids and to give him Miralax (laxative)." "I brought him back to the emergency department a third time because he couldn't keep anything down and he wasn't getting better." "The nurse called for an ambulance that took us to [Hospital C] because my son was very dehydrated."

2. Review of a second medical record of patient # 20 revealed that he was brought back to the ED on 8/17/14, at 3:36 AM, about 24 hours after discharge complaining of vomiting and constipation.


ED nurse B triaged the patient as urgent. At 4:05 AM, ED physician # 7 examined patient # 20 and documented that he had chronic constipation with known bowel obstruction in the past; mom stated that he has been vomiting everything she gives him since 9:00 AM and that he vomited up all his medication that day too.


Further documentation revealed that patient # 20's home medications included Senna (laxative), Miralax, Tegretol (anti-seizure medication), Clonazepam (anti-seizure medication) and one other medication.


At 4:30 AM, ED nurse B documented she inserted an IV catheter to obtain blood for laboratory testing and to infuse 270 ml IV fluid bolus.


At 4:37 AM, ED physician # 7 ordered laboratory testing that included a complete blood count.


At 4:38 AM, patient # 20 received anti-nausea medication IV and a second 270 ml fluid bolus.


At 5:50 AM, patient # 20 was transported to radiology for an abdominal x-ray. The radiology report showed that patient # 20 had "considerable stool in the colon, the rectum is filled with solid stool." "Dilated small bowel persists consistent with mechanical small bowel obstruction."


At 6:30 AM, ED nurse B documented patient # 20 received ½ Fleets enema, at 6:45 AM the patient expelled the enema solution without passing any stool, and following that, a ½ of a Dulcolax suppository was inserted.


At 7:00 AM, ED nurse B documented she notified ED physician # 7 that the patient did not pass any stool following the suppository and that the patient was "grunting, grinding his teeth, sticking his fingers down his throat," and that the patient appeared agitated.


At 7:10 AM, a second ½ of a Dulcolax suppository was inserted, and at 7:30 AM a scant amount of brown liquid was passed but no formed stool. ED nurse B documented that she notified ED physician # 7 who ordered administration of the second half of a Fleets enema.


At 7:45 AM, patient expelled a large hard formed stool and was discharged.


Further documentation revealed that ED physician # 7 went out to the parking lot and brought patient # 20 back into the ED and at 8:10 AM the patient received an intramuscular injection (IM) of an anti-nausea medication and was once again discharged.


The medical record did not contain evidence that patient # 20's emergency medical condition was stabilized at the time of discharge. ED physician # 7 did not document a review or interpretation of the laboratory tests that were performed.


Review of the clinical laboratory report showed unreliable results, specifically the time noted for blood collection for some lab tests was 8/17/14 around 4:41 AM and the blood collection for other lab tests was dated 8/19/14 at 4:06 PM, over 48 hours after patient # 20 was discharged. The results of all the 8/17/14 lab testing were not entered into the medical record until 8/19/14 at 4:06 PM. The lab report showed the patient had an abnormal high white blood cell count of 15.2 K/cmm3 (an increase from 8/15/14) and a low potassium level of 3.3 millimoles/Liter (normal 3.6 - 5.0 mmol/Liter, low potassium can cause life threatening changes in the heart rhythm).


Additionally, ED physician # 7 did not order a blood test to measure patient # 20's anti-seizure medication (Tegretol) levels to determine whether they were normal in light of his vomiting and dehydration on 8/15/14 nor on the second ED visit on 8/17/14, or repeat the potassium level to monitor for further changes following the fluid boluses.


3. Review of a third medical record of patient # 20 revealed that he was brought back to the ED on 8/18/14, at 5:21 PM, approximately 32 hours after discharge on 8/17/14. ED nurse F documented patient # 20's parent stated "this is the third time we have brought him in, they keep sending us home."

At 6:06 PM, ED nurse F attempted to start an IV but was unsuccessful. ED physician # 8 examined patient # 20 and documented that the patient was listless, had a weak cry, almost limp, dazed gaze, sunken eyes, had shallow respirations, a rapid heart rate, very distended abdomen, and was severely dehydrated and had intractable vomiting and required an IV bolus and "immediate transfer."

Further documentation revealed that patient # 20 was transported to Hospital C by BLS ambulance. The medical record did not contain evidence that ED physician # 8 provided further examination and stabilizing treatment to patient # 22 including inserting an IV catheter or an intraosseous needle (inserted into the bone as an effective alternative to failed IV access) to obtain blood for testing or administration of fluids, or arranged transport by an ambulance equipped to provide advanced cardiac life support measures to this patient with an unstable emergency medical condition.

Review of Hospital C's medical record of patient # 20 revealed that he arrived in the ED on 8/18/14, at 7:21 PM, in an unstable emergency medical condition. Blood collected for lab testing at 7:29 PM revealed that patient # 20 had a critically low potassium level which was lower than, but consistent with the low potassium obtained at Winnebago IHS Hospital on 8/17/14. Staff at Hospital C provided initial treatment and subsequently arranged patient # 20's transfer by ALS ambulance to Hospital D for admission and further treatment to stabilize his emergency medical condition.

In an interview on 8/25/14, ED nurse G reviewed the contents of the ED pediatric crash cart and confirmed that an intraosseous catheter insertion kit was available and that ED staff were capable of inserting the catheter.