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Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#25) of 36 Emergency Department (ED) records reviewed from 05/2022 through 11/2022. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's combined average monthly ED census over the past six months was 3,516.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Patient Transfer Policy," dated 02/03/22, showed that any individual that presents to the ED or any location on the hospital campus, and requests a medical examination or treatment, should receive a MSE within the department's capability, including ancillary services, to determine if an EMC exists. An EMC would be any medical condition manifested by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) which could impair bodily function or result in the dysfunction of any body organ or part. The hospital must provide an appropriate MSE.

Review of the hospital's provider education document titled, "Emergency Medical Treatment & Labor Act (EMTALA) - Review and Hot Issues," dated 02/07/22, showed that hospitals should provide a MSE to determine whether a patient had an EMC. An EMC would be any medical condition manifested by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) which could impair bodily function or result in the dysfunction of any body organ or part.

Review of the hospital's policy titled, "Pain Management," dated 09/2022, showed that based upon the patient's pain assessment, staff should implement pharmacological or non-pharmacological interventions to provide adequate pain relief. On a numerical scale of zero to 10, a rating of one to three would be considered mild pain, a rating of four to seven would be considered moderate pain, and any rating of eight to 10 would be considered to be severe pain. Any education or interventions related to pain should be documented in a narrative note, along with effectiveness of those interventions.

Review of the hospital's policy titled, "Interpretation of Emergency Room Exams," dated 09/2022, showed that emergency room providers would provide a preliminary interpretation on all diagnostic x-rays (test that creates pictures of the structures inside the body-particularly bones), except those ordered stat (immediately). Within 24 hours a radiologist would re-examine those x-rays and generate a final interpretation. In the event of a discrepancy in findings, the ED provider on duty would be contacted to notify the patient and/or their physician regarding the discrepancy to ensure appropriate treatment was provided.

Review of Patient #25's ED medical record, dated 09/20/22 at 4:08 PM, showed that:
- She was a 63-year-old female that presented to the ED for evaluation via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.).
- She had fallen at home during the night and had been unable to get up or call for assistance.
- She had suffered multiple falls over a couple of days.
- She complained of bruising to her left side and pain to her left ribs with breathing.
- At 4:47 PM, the hospital received a phone call from Patient #25's outpatient counselor, who expressed concerns about Patient #25's ability to care for herself at home. She had suffered numerous falls and laid on the floor for extended periods of time.
- At 5:50 PM, Patient #25 expressed that her pain level was an eight out of 10 on the pain scale, continuous and aching.
- At 5:52 PM, hip and chest x-rays were ordered.
- At 5:53 PM, Staff P, Physician Assistant (PA), documented that Patient #25 had been seen one month prior and had been diagnosed with severe degenerative disease of her left hip. She had voiced to him that she was having more difficulty with ambulation and had fallen. She complained of left hip and rib pain.
- At 5:54 PM, Staff P, PA, documented that upon palpation, Patient #25 had moderate tenderness of her left upper chest and left breast area.
- At 5:56 PM, Staff P, PA, documented that Patient #25 had been medically screened.
- At 6:31 PM, hip and chest x-rays were completed.
- At 6:35 PM, Staff P, PA, entered discharge orders for her to be discharged to home with self-care; her diagnoses were rib contusions and left hip pain, her symptoms were unchanged.
- At 6:44 PM, Staff O, Registered Nurse (RN), documented that Patient #25's pain level was unchanged.
- At 6:49 PM, Staff O, RN, documented that Patient #25 was assisted to a wheelchair and was to be discharged to home.
- At 6:50 PM, Staff O, RN, documented that Patient #25 had left the ED.
- On 09/21/22 at 6:49 AM, documentation showed that Patient #25's chest x-ray results were finalized and showed that she had moderately displaced rib fractures (a break in a bone) at rib eight and nine, with minimal displacement of rib fracture 10.

Please refer to 2406 for further details.

Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity an appropriate medical screening examination (MSE) for one patient (#25) out of 36 Emergency Department (ED) records reviewed from 05/2022 through 11/2022. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 3,516.

Findings included:

1. Review of the hospital's undated document titled, "Poplar Bluff Regional Medical Center Rules and Regulations," showed that individuals that present to the ED shall be provided a MSE to determine whether or not they are experiencing an EMC. An EMC is defined as a condition manifesting in symptoms that may cause serious dysfunction or impairment to bodily organs or function.

Review of the hospital's policy titled, "Emergency Medical Treatment and Patient Transfer Policy," dated 02/03/22, showed that an EMC would be any medical condition manifested by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) which could impair bodily function or result in the dysfunction of any body organ or part. The hospital must provide an appropriate MSE.

Review of the hospital's provider education document titled, "Emergency Medical Treatment & Labor Act (EMTALA)-Review and Hot Issues," dated 02/07/22, showed that the hospital should provide a MSE to determine whether a patient had an EMC. An EMC would be any medical condition manifested by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) which could impair bodily function or result in the dysfunction of any body organ or part.

Review of the hospital's policy titled, "Pain Management," dated 09/2022, showed that based upon the patient's pain assessment, staff should implement pharmacological or non-pharmacological interventions to provide adequate pain relief. On a numerical scale of zero to 10, a rating of one to three would be considered mild pain, a rating of four to seven would be considered moderate pain, and any rating of eight to 10 would be considered severe pain. Any education or interventions related to pain should be documented in a narrative note, along with effectiveness of those interventions.

Review of the hospital's policy titled, "Interpretation of Emergency Room Exams," dated 09/2022, showed that emergency room providers would provide a preliminary interpretation on all diagnostic x-rays (test that creates pictures of the structures inside the body-particularly bones), except those ordered stat (immediately). Within 24 hours, a radiologist would re-examine those x-rays and generate a final interpretation. In the event of a discrepancy in findings, the ED Physician on duty would be contacted to notify the patient and/or their physician regarding the discrepancy to ensure appropriate treatment was provided.

Review of the hospital's policy titled, "Trauma Patient Initial Assessment in the ED," dated 06/30/20, directed staff to address a patient's airway, breathing, circulation, disability, exposure, obtain a full set of vital signs, assess pain, administer appropriate non-pharmacologic comfort measures and obtain an order for analgesic medications, if able.

Although requested, the hospital failed to provide an ED policy specific to the consultation of Case Management/Social Work staff.

Review of Patient #25's "Pre-hospital Care Report with attachments," dated 09/20/22, showed that:
- EMS had responded to her home at 3:15 PM, for a report that she had fallen.
- She was a 63-year-old female with a history of diabetes, degenerative disc disease (condition of the discs along the spine when they lose cushioning, fragment and herniate due to aging), and asthma (a condition in which the airways narrow and swell making it difficult to breathe).
- Patient #25 was found lying on the floor of her bedroom, rocking back and forth, with uncontrollable mouth movements.
- Her breathing was rapid and irregular, but lung sounds were clear.
- She had fallen sometime during the night, impacting a table and had been unable to get up, lying on the floor for several hours.
- She complained of pain to her side as a result of her fall.
- She reported that she had fallen several times over the last couple of days.
- No medications were listed.
- The ambulance arrived at the hospital at 4:04 PM.

Review of Patient #25's ED medical record, dated 09/20/22 at 4:08 PM, showed that:
- She was a 63-year-old female that presented to the ED via EMS for evaluation after suffering a fall during the night, unable to get up or phone for help.
- Her primary complaint was bruising to her left side and pain with breathing.
- Her medical history included multiple falls over the last couple of days, insulin-dependent diabetes mellitus (IDDM, a form of diabetes in which patients have little or no ability to produce insulin), asthma, degenerative disc disease, migraines and methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) abuse.
- At 4:47 PM, the hospital received a phone call from Patient #25's outpatient care coordinator, who expressed concerns about Patient #25's ability to care for herself at home, since she had recently suffered numerous falls and ended up lying on the floor for extended periods of time.
- At 5:50 PM, Patient #25 expressed that her pain level was an eight out of 10 on the pain scale, continuous and aching.
- At 5:52 PM, hip and chest x-rays were ordered.
- At 5:53 PM, Staff P, Physician Assistant (PA), documented that Patient #25 had been seen one month prior and had been diagnosed with severe degenerative disease of her left hip. She had voiced to him that she was having increased difficulty with ambulation and frequent falls. She complained of left hip and rib pain.
- At 5:54 PM, Staff P, PA, documented that upon palpation, Patient #25 had moderate tenderness of her left upper chest and left breast area.
- At 5:56 PM, Staff P, PA, documented that Patient #25 had been medically screened.
- At 6:31 PM, hip and chest x-rays were completed.
- At 6:35 PM, Staff P, PA, entered orders for the patient to be discharged to home with self-care; her diagnoses were rib contusions and left hip pain, her symptoms were unchanged.
- At 6:44 PM, Staff O, Registered Nurse (RN), documented that Patient #25's pain level was unchanged.
- At 6:49 PM, Staff O, RN, documented that Patient #25 was assisted to a wheelchair and was to be discharged to home.
- At 6:50 PM, Staff O, RN, documented that Patient #25 had left the ED.
- On 09/21/22 at 6:49 AM, documentation showed that Patient #25's chest x-ray results were finalized by Radiology and showed that she had moderately displaced rib fractures at ribs eight and nine, with minimal displacement of rib 10.

During an interview on 12/05/22 at 9:30 AM, Staff T, Paramedic, stated that he had responded to the EMS call for Patient #25, when she had fallen during the night and hit her side on a table. She told him that she had been unable to get up and had laid on the floor for hours. When he assessed her, her only complaint had been the pain to her left side. He had been able to assist her on to the stretcher for transport to the hospital. Upon their arrival at the hospital, he provided the bedside nurse with Patient #25's history. He would normally review the patient's medication list that family supplied, or he would contact their pharmacy. That would be documented in his notes and/or given to the hospital. He did not recall obtaining a list from Patient #25.

During an interview on 12/01/22 at 12:00 PM, Staff O, RN, stated that she had been the primary nurse for Patient #25, but could not recall specifics about the patient. She would have completed a head to toe assessment (complete assessment of all patient body systems, including heart, lung, skin, vital signs [body temperature, blood pressure, heart rate, and breathing rate], etc.), pain assessment, obtained a medical history, the current complaint, any medication allergies, and reviewed their home medications. Pain assessments and vital signs should be re-assessed every 30 minutes, but sometimes this did not occur due to the acuity (the severity of a patient's illness and the level of service needed) and/or the number of patients nurses were assigned. When a patient complained of pain, she would alert the provider. Staff P, PA, would have been in the room with her when she obtained Patient #25's history and been aware of any complaints of pain. She could not recall if Patient #25 had requested any pain medications and was unable to locate any notations of requests or a list of medications for Patient #25 in her ED medical record. Any patient with a pain rating of eight out of 10 would require the nurse to implement interventions. There were no notes in Patient #25's ED medical record about interventions put in place. She did not recall any concerns being voiced about Patient #25's ability to care for herself. ED nursing staff had access to a Case Manager (CM) or Social Worker (SW) if needs were identified for a patient, such as assistive devices and/or placement in a nursing facility. She did not consult a CM or SW for Patient #25. Discharge transportation arrangements would be made by the bedside nurse. There were no notes in Patient #25's ED medical record to indicate how she was transported home. The bedside nurse would contact the patient's family members, their residential home, or a transport service to arrange transportation. When patients used a transport service, they would be placed in the waiting room to await their arrival. The nurse would alert the admitting clerks that the patient was awaiting pick up by a transport service. A patient's wait could be several hours for the transport service.

During an interview on 01/19/23 at 3:05 PM, Staff R, Admitting Clerk, stated that she did not recall Patient #25. Patients that have been discharged from the ED that required transportation through the transport service could be at the hospital all night. Transport services usually stopped picking patients up between 5:00 PM and 7:00 PM.

During an interview on 11/30/22 at 9:20 AM, Staff H, RN, stated that he had not had any interaction with Patient #25. He was the charge nurse that day and he had received a phone call from the patient's care coordinator at the Family Counseling Center. He documented her concerns regarding Patient #25 having suffered multiple falls with extended periods of time lying on the floor. He did not speak with the primary nurse or the provider regarding the concerns that were voiced during that conversation. The ED staff would set up any discharge transportation that a patient may need. The Medicaid transport provider provided the hospital with a pick up time window and that window may be a few hours. The patient would then be placed in the waiting room and the registration clerk would be made aware that they were awaiting transport. Providers read their own x-rays, but a radiologist also read them. In the event of a discrepancy, the radiologist would notify the charge nurse or a provider. They would contact the patient and then place an addendum in the medical record annotating that the patient had been notified. When patients voiced complaints of pain, that information should be relayed to the provider. The nurse should advocate for the patient and document any reasoning for not addressing the pain.

During a phone interview on 12/01/22 at 3:00 PM, Staff P, PA, stated that he had been the provider assigned to care for Patient #25. Her chief complaint had been pain with breathing after she had suffered a fall at home. His initial concern was a possible hip fracture, rib fracture, or a pneumothorax (the presence of air or gas in the cavity between the lungs and the chest wall, causing collapse of the lung). With any falls, initial testing would include x-rays of the hip and/or chest and potentially a computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) if any abnormalities were detected on the x-rays. Any laboratory testing would depend upon on whether or not the patient had indicated weakness, fever, or if their vital signs were abnormal. Patient #25 had told him that she had been having frequent falls and was in the process of working with her primary care provider to obtain a wheelchair. She had been seen in the ED previously for hip pain and he had been able to compare the hip x-rays from both visits. There had been no changes in her hip x-rays and while he reviewed the chart for this interview, he discovered that he had misdiagnosed her rib fractures. He had been unaware of the radiologist's final impression that Patient #25 had suffered two moderately displaced and one minimal displaced rib fractures. He had not been notified of the discrepancy. Had he been informed, he would have placed an addendum to the medical record with that information. Someone should have contacted the patient or her primary physician and notated that in the medical record. There were no notes or addendums within Patient #25's ED medical record, which indicated that she had not been informed of the rib fractures. He had not been informed that Patient #25's outpatient care coordinator had voiced concerns about her ability to continue to care for herself at home. He could have ordered a CM or SW consult to address those concerns. Patient #25 did not have any consults ordered. He was unsure if he reviewed Patient #25's medications or not, and had been unable to locate a current list within the ED medical record. A current list of medications was an important part of a patient's assessment and he would have expected that information to have been in the ED medical record. There was no medication list in Patient #25's ED medical record.

During a phone interview on 12/05/22 at 2:50 PM, Staff U, Family Counseling Center (FCC) Care Coordinator, stated that when she arrived at the hospital, the ED staff could not tell her where Patient #25 was located. She was not in the ED, but outside by another entrance.

During an interview on 11/30/22 at 9:55 AM, Staff I, SW, stated that she was assigned to cover the needs of the ED on 09/20/22, between 7:30 AM and 4:00 PM. She would have been available upon consult to arrange discharge transportation for any patients with a need. The expectation would be that the patient was picked up within three hours. She was not contacted by the ED to arrange transportation for Patient #25.

Although requested, the hospital failed to provide documentation of Patient #25's medications list for her ED visit on 09/20/22.

In response to the video request, the team was provided with an internal electronic mail (e-mail). Review of an internal e-mail, dated 11/28/22, addressed to Staff C, RM/CO, showed that the hospital's server failed in June 2022. The information technology department was unable to restore or recover any video documentation for the ED ambulance entrance/exit or the main ED hospital entrance/exit for 09/20/22 through 09/21/22.

Although requested, the hospital failed to provide documentation that either Patient #25 or her physician of record were contacted with the radiologist's updated interpretation of her chest x-ray which showed that she had moderately displaced anterolateral left eighth and ninth rib fractures and a minimally displaced 10th rib fracture.

During an interview of 11/29/22 at 1:45 PM, Staff A, ED Manager, stated that over-reads of x-rays were usually completed within 24 hours. If there were discrepancies found, the radiologist would contact the ED to notify the charge nurse or a provider of the error. The charge nurse or provider would then contact the patient or their physician regarding the results. That would then be documented in the medical record, along with the number of attempts to reach the patient and what information was relayed to them.

During a phone interview on 12/05/22 at 8:05 AM, Staff Q, Physician (MD), stated that he had not interacted with Patient #25. When supervising a PA, he would have been available for any questions, concerns, and support related Patient #25's visit. PAs were trained to read simple radiology films on their own. He would only be involved if there were questionable results or if advanced imaging had been completed. PAs were responsible for and trained to complete physical exams, interpret laboratory results, and to review imaging films. All the data they obtain should be documented within the patient's ED medical record. He had been unaware that Patient #25 had suffered multiple falls until he signed off on the chart after she had been discharged. He would not have changed her treatment plan without performing his own assessment. Nursing staff should not only document concerns voiced by family and/or caregivers in the patient's ED medical record, but verbally notify the provider as well. All concerns of the patient and/or family/caregiver should be addressed by the provider prior to discharge, including pain management. A patient's age, history, injury, mechanism of injury, and medications would all impact whether or not laboratory testing would be ordered. Patients with single or simple injuries could be treated based on x-rays alone. The nursing staff should review medications with each patient and update their medical records accordingly. A current medication list should be reviewed by the provider for each patient. He was unable to locate a current medication list within Patient #25's ED medical record. Anytime a radiologist's final reading of an x-ray differs from an initial provider's impression, the radiologist should notify the ED staff. Either the charge nurse or the provider on duty would contact the patient to notify them of the need to be re-assessed. The conversation should include their current condition, whether or not they have seen another provider or have an upcoming appointment, and/or a plan for treatment. He would expect this to be annotated in the patient's ED medical record. He was unable to locate any notes or addendums related to the final x-ray impression for Patient #25's rib fractures.

During an interview on 11/29/22 at 3:40 PM, Staff L, Chief Quality Officer (CQO), stated that the hospital did not track misreads of x-ray films.

During a phone interview on 12/05/22 at 3:25 PM, Patient #25, stated that she had fallen at home on 09/20/22, and she was on the floor for several hours before EMS arrived. During triage (process of determining the priority of a patient's treatment based on the severity of their condition) at the hospital, she told the nurse that she had hip pain and left side chest pain every time she took a breath or coughed. She rated her pain as an eight out of 10 on the pain scale. The hospital did not do much for her, they took a couple of x-rays and then discharged her. A radiology technician told her that the x-rays were unchanged from her previous visit. She had been aware that she was in need of a total hip replacement, but her concern was that she may have shattered what was left of her hip when she fell. She was not aware that the chest x-rays had shown that her eighth, ninth, and 10th ribs were fractured until this conversation. She thought they might have been fractured due to the amount of pain she had been in. No one in the ED addressed her pain level or offered her any medication for pain. She had assumed they wouldn't give her anything since she had a history of drug abuse in the past. They discharged her around 7:00 PM. They placed her in a wheelchair and rolled her out to the receptionist. The receptionist told her that she would have to wait until morning for the transportation service, which was not unusual, the wait times were always long. She had wheeled herself outside of the hospital to smoke and had been told by security to move away from the entrance. She stated that she had slipped out of the wheelchair while outside. Early the next morning, a visitor noticed her, assisted her into her wheelchair and allowed her to use their cell phone so that she could contact her care coordinator. When the care coordinator arrived at the hospital to pick her up, the hospital staff were unsure where she was and were unwilling to share any information with her. Her care coordinator found her, picked up some breakfast for her, and drove her home. The care coordinator was concerned because Patient #25 was an insulin dependent diabetic. No one from the hospital offered to assist her with locating transportation, offered her food or water, or offered to make a phone call for her.