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Based on review of documentation and interviews with facility staff, the facility failed to provide an appropriate and thorough medical screening examination (MSE) within the capability of the hospital's emergency department, including gastroenterology or gynecology consultations and pelvic ultrasound available to the emergency department, to determine whether an emergency medical condition (EMC) existed for 1 of 41 (Patient #1) patients reviewed that presented to the emergency department (ED). Patient #1 presented to the ED in acute distress complaining of 10 out 10 lower abdominal pain. The patient had a CT Abdomen Pelvis with contrast completed and the radiologist report indicated ovarian cysts on left and right ovary and recommended a pelvic ultrasound for further evaluation. No gastroenterology or gynecology consultation was obtained by the ED, and the patient's symptoms did not resolve prior to being discharged home with a last pain score of 9 out of 10. The patient was seen at a different ED the next day, received another CT and was diagnosed with an internal hernia and small bowel obstruction, which required surgical intervention.

The findings were:

Patient #1's medical record from Hospital A was reviewed, it was noted:
Patient #1 was seen on 7/12/23 complaining of "lower abdominal pain that started 3 PM today 10 out of 10 in nature. She is in acute distress due to the pain. Says it happened 11 days ago with similar presentation when she went to the ER and was told she had food poisoning. She was okay in the interim. She is also been having multiple episodes of nonbilious nonbloody emesis." A CT Abdomen Pelvis with contrast was performed and the radiologist's report indicated, "Findings suggestive of 4.9 x 3.1 cm left ovarian cyst and 2.6 and 2. 6 cm right ovarian cyst. Recommend pelvic ultrasound for further evaluation." The ED physician's notes indicated, "This patient presents with abdominal pain of unclear etiology. A CT scan was performed to evaluate for potential causes of the abdominal pain, however, neither the clinical exam nor the CT has identified an emergent etiology for the abdominal pain. Specifically, given the benign exam, the laboratory studies, and unremarkable CT, I have a very low suspicion for appendicitis, ischemic bowel, bowel perforation, or any other life threatening disease." During this visit, Patient #1 received 8mg morphine, 50mcg fentanyl, and 30mg ketorolac. The patient's last assessed pain score of "9" was recorded at 2202 and the patient was discharged at 2251. No documentation indicate that gastroenterology or gynecology was consulted by ED physician. Review of the on-call schedule for 7/12/23 indicated both services were available for consults. The consults could have assisted the ED physician in determining need for admission and further testing or discharge with prompt follow-up.


Interviewed Staff #7 (the ED physician that took care of Patient #1 on 7/12/23) via email on 11/14/23.

Surveyor: What do you remember about this particular patient?

Staff #7: "From what I remember in July, she was having bouts of abdominal pain with n/v. She was seen 11 days earlier for similar GI sx. She was not peritonitic on exam. Her CT showed 5cm ovarian cyst on left and 2.6cm cyst on right. No free fluid in pelvis. She wasn't septic. She improved after morphine and Zofran."

Surveyor: The CT abdomen/pelvis radiologist report recommended a pelvic ultrasound for further evaluation. Was a pelvic ultrasound performed? If no, why not?

Staff #7: "No ultrasound was done as there wasn't any secondary signs of inflammation or rupture of the cysts to indicate an emergent ultrasound."

Surveyor: Was there an immediate/emergent need to transfer the patient to a higher level of care or service not provided by this hospital?

Staff #7: "There was not an immediate need for transfer at the time of my evaluation."


Patient #1's medical record from Hospital B was reviewed, it was noted:
Patient #1 was seen at the ED of Hospital B on 7/13/23 complaining of "abdominal pain that started since 6/29 was seen and treated for gastroenteritis. Pt stated pain is recurrent and worse since yesterday with vomiting." A CT Abdomen/Pelvis with contrast was completed and the report revealed, "A markedly dilated short-segment of small bowel in the left lower quadrant is mildly to moderately inflamed, oriented in a loop, and demonstrates marked narrowing of the small bowel at both ends of the loop compatible with closed loop small-bowel obstruction, possibly secondary to internal hernia ... The small bowel loops proximal to the closed loop obstruction are moderately dilated and organized with air-fluid levels, again compatible with small-bowel obstruction." General surgery and gastroenterology were consulted and Patient #1 was admitted to the hospital for a small bowel resection.