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Based on interview, record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#3 and #21) of 34 Emergency Department (ED) and Labor and Delivery records reviewed.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," dated 10/01/24, showed:
- Barnes-Jewish-Christian (BJC) HealthCare is committed to providing patients with emergency medical care that meets or exceeds the requirements of EMTALA.
- Individuals who come to the ED and request emergency care or treatment will receive an appropriate MSE beyond medical triage (process of determining the priority of a patient's treatment based on the severity of their condition) provided by qualified medical personnel.
- The MSE must be within the hospital's capacity and capability and include ancillary services routinely available to determine if an EMC exists.
- The hospital must utilize the routinely available ancillary services to conduct the MSE.
- No patient will be discharged or transferred without a MSE.

Review of the hospital's undated policy titled, "Abuse/Neglect (Child/Disabled/Domestic/Elder/Patient Abuse)," showed:
- Abuse is defined as any physical injury, sexual or emotional abuse inflicted on a child other than by accidental means by those responsible for the child's care, custody and control.
- The physical assessment includes indicators of abuse such as multiple bruises at different stages of healing.
- If health care workers observe the abuse of a child or suspect a child has been abused, they are to immediately notify the child's primary physician, social work and the nursing supervisor.
- When the child exhibits any visible signs of abuse, the nurse and/or social worker shall inform the physician of the need to document with photographs of the injury.
- The social worker shall complete the psychosocial assessment, including assessment of physical indicators and history of abuse. The assessment shall be documented in the medical record.
- Interview the child privately in a quiet room without interruptions. Obtain the history from the parent/guardian outside the presence of the child. Before screening for abuse, it is essential to create an environment of safety and privacy.
- Document assessment, findings and actions taken in the medical record.
- A DFS hotline report must be made if abuse is suspected following the evaluation.
- Possible characteristics of the abuser include mental illness.

Review of the hospital's undated policy titled, "Parkland Health Center-Assessment/Reassessment of the ED Patient," showed the registered nurse (RN) will perform an assessment including the patient's vital signs (VS, measurements of the body's most basic functions, blood pressure (BP) normal between 90/60 and 120/80; pulse/heartbeats (HR) normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; body temperature (T) normal 97.8 to 99 degrees and oxygen saturation (SAO2) measure of how much oxygen is in blood. A normal is between 95% and 100) including a pain assessment. Routine reassessment will occur throughout the patient's emergency visit.

Review of the hospital's policy titled, "Pain: Acute Pain Assessment and Management," dated 02/26/24, showed a pain score is required with routine VS using a pain scale appropriate to the patient's age, level of understanding and cultural background as determined by the patient and/or licensed care provider. The nurse is responsible for a pain assessment to determine appropriate interventions based upon the patient's reported pain score.

Based on observation, interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#3 and #21) of 34 Emergency Department (ED) and Labor and Delivery records reviewed.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," dated 10/01/24, showed:
- Barnes-Jewish-Christian (BJC) HealthCare is committed to providing patients with emergency medical care that meets or exceeds the requirements of EMTALA.
- Individuals who come to the ED and request emergency care or treatment will receive an appropriate MSE beyond medical triage (process of determining the priority of a patient's treatment based on the severity of their condition) provided by qualified medical personnel.
- The MSE must be within the hospital's capacity and capability and include ancillary services routinely available to determine if an EMC exists.
- The hospital must utilize the routinely available ancillary services to conduct the MSE.
- No patient will be discharged or transferred without a MSE.

Review of the hospital's undated policy titled, "Parkland Health Center-Assessment/Reassessment of the ED Patient," showed the registered nurse (RN) will perform an assessment including the patient's vital signs (VS, measurements of the body's most basic functions) including a pain assessment. Routine reassessment will occur throughout the patient's emergency visit.

Record review of Patient #3 's medical record showed:
- On 01/02/25 at 12:10 AM, he was a nine-year-old who presented to the ED with a complaint of vomiting.
- His past medical history included intussusception (a life-threatening condition that occurs when part of the intestine folds into another part, blocking food and blood flow), oppositional defiant disorder (ODD, a disorder marked by defiant and disobedient behavior to authority figures), attention deficit/hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors) and constipation.
- His mother had a psychiatric (relating to mental illness) history of personality disorder (a type of mental disorder in which a person has a rigid and unhealthy pattern of thinking, functioning and behaving). His father had a psychiatric history of bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows).
- At 12:30 AM, his VS were blood pressure (BP) 108/73, heart rate (HR) 85, respiratory rate (RR) 18 and temperature (T) 97.2. There was no assessment of his current pain level, only a stated pain goal of seven.
- At 12:31 AM, an abuse assessment showed a denied past or current harmful physical or emotional relationship. A denial of someone making him afraid or unsafe. He had a safe place to go at discharge. There was no documentation of who answered the questions or who was present in the room during questioning.
- At 12:34 AM, orders were placed for a urinalysis (UA, a laboratory examination of a person's urine), a streptococcal (a bacteria) throat swab, a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and a comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions).
- At 1:04 AM, the streptococcal swab was negative.
- At 1:42 AM, he played on an electronic tablet, rolled around on a stretcher, laughed and asked for chips. He reported a bowel movement the previous day that was like "rabbit turds," and vomited five times since 9:30 PM. He showed no visible distress or discomfort and the nurse planned to wait for the provider's evaluation before collecting the ordered laboratory studies.
- There was no nursing skin assessment.
- At 2:25 AM, his review of symptoms showed abdominal pain, constipation, nausea and vomiting. His skin assessment was negative for rash and wound. He was visibly anxious and argumentative.
- At 3:02 AM, he was provided ice chips by the physician and instructed to "consume slowly."
- At 5:07 AM, a kidney, ureter, and bladder x-ray (KUB; assesses the structures of the urinary and/or gastrointestinal system) showed an increased stool burden (the amount of stool in the colon).
- At 5:00 AM, his vital signs were HR 82 and SPO2 100%. No reassessment of his BP, RR or T was performed.
- At 5:12 AM, he was discharged with a diagnosis of constipation, nausea and vomiting with instructions to take a laxative (a medication that treats constipation) daily for three days and then as needed to achieve a soft stool every day and to return to the ED with worsening abdominal pain, uncontrolled vomiting or fever.
- The CBC, CMP and UA were not performed which is concerning in the context of abdominal pain, nausea and vomiting in that the presence of other Emergency Medical Conditions were not sufficiently ruled out.

During a telephone interview on 01/14/25 at 12:00 PM and 01/15/25 at 3:28 PM, Staff G, Physician, stated that he had a vague recollection of Patient #3. He did not recall a facial injury. Patient #3 was resistant to blood draws and had a benign assessment. A KUB is "never enough" to diagnose constipation. The KUB determined Patient #3 did not have a "surgical" abdomen. Patient #3 was discharged home and told to come back if his condition worsened. He expected documentation of the oral challenge tolerance. He expected laboratory study orders to be discontinued when the decision was made to not complete the orders.

During an interview on 01/16/25 at 1:13 PM, Staff B, Chief Nursing Officer (CNO), stated that she expected documentation of an oral challenge tolerance. She typically saw an oral challenge begin with ice chips and then advance as tolerated. She expected documentation of why the ordered laboratory studies were not completed. She expected the orders to be discontinued.
During an interview on 01/14/25 at 4:10 PM and 01/16/25 at 12:56 PM, Staff X, ED Manager, stated that she expected documentation of a skin assessment with a visible injury. Upon review of Patient #3's medical record she stated that the injury "looked pretty visible." She expected documentation of an oral challenge tolerance. She expected a thorough pain assessment in triage and prior to discharge. She expected staff to follow the abuse policy if abuse was suspected. An event report was not always completed when child abuse was observed. The hospital had a learning opportunity with the policy for abuse. If a provider decided not to perform previously ordered laboratory studies, she expected the orders were discontinued. She expected documentation of why the laboratory studies were not performed. She was not notified of Patient #3's DFS hotline. Typically, she was only notified of a DFS hotline if there was something "unusual."

During a telephone interview on 01/15/25 at 9:22 AM and 01/16/25 at 10:15 AM, Staff J, RN, stated that she did not see the facial injury during Patient #3's first ED visit. She stated that Patient #3 appeared to be in pain. She did not know why she documented a stated pain goal of seven. He did not rate his pain with a number. He intermittently grimaced and held himself with the pain. The pain appeared to be "spasmodic." She ordered laboratory studies per protocol because she could not in "good conscious" dismiss his pain. She reported her assessment to his primary nurse. She believed the laboratory studies were necessary. Patient #3 had behavioral issues and she was concerned his behavior could have been a deterrent to his care. She assessed "some level of dysfunction" between Patient #3 and his mother. She did not review the chart for a history of abuse "she was too busy." She felt Patient #3's mother may have been "battered" herself, she did not want to make Patient #3 "mad." She believed the family was involved with social work because the mother seemed engaged, passive and structured when managing Patient #3. She performed the abuse assessment with the patient and his mother in the room. Both answered the abuse questions.

During a telephone interview on 01/15/25 at 11:40 AM, Staff K, RN, stated that she did not remember the report she received from Staff J, RN. If a child did not show distress, laboratory studies ordered per protocol were held until the patient was evaluated by the provider. She questioned the parent's regarding how the child was behaving. She did not document "everything that was said." If a provider decided the laboratory studies were not necessary, the orders were discontinued. She did not recall Patient #3's facial injury. "In a perfect world," she expected documentation of an oral challenge tolerance if she performed the assessment. If she was "too busy," she may not document something not "notable." She may not document 100 percent of the time if there were other critical issues.

During a telephone interview on 01/15/24 at 3:00 PM, Staff M, RN, stated that Patient #3's injury was easily visible and appeared red, yellow and green. She was confident Patient #3's injury did not occur after his discharge that morning and was present during his previous visit. Patient #3's mother pointed out the older bruising. She completed a full assessment after she identified the facial injury. She expected documentation of an oral challenge tolerance. She stated that she would have obtained the laboratory studies based on the triage nurse's assessment. The provider stated that Patient #3 appeared lethargic (weak, sluggish). Patient #3 was transferred to Hospital B because the antinausea medication and oral challenge failed. It was hard for her to say if Patient #3 was fully evaluated during his prior ED visit. If a patient asked for food with abdominal pain, she needed to see him/her tolerate the food to determine if his/her condition improved. "Lots of people ask for food with abdominal pain, they think the pain is from hunger."
Review of Patient #21's medical record, showed:
- On 12/03/24 at 3:29 PM, she was an 85-year-old who presented to the ED with confusion and weakness after a recent fall and suspicion for a seizure disorder (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness).
- Her past medical history included chronic kidney disease (CKD, ongoing, gradual loss of kidney function), dizziness, bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and schizo-affective disorder (mental health disorder where speech and thought are disorganized, and a person may find it hard to function socially and at work and may experience hearing voices that are not real).
- At 3:48 PM, her complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) showed her white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 3.8-9.9) was 21.4.
- At 3:53 PM, the physician reviewed her CBC and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) from 08/23/23 that showed her WBC count was 10.10 and creatinine (blood test that shows how the kidney is functioning, normal is 0.6 to 1.1) was 1.03.
- At 4:38 PM, her urinalysis (UA, a laboratory examination of a person's urine) was within normal limits.
- At 5:11 PM, a head computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) showed chronic (long term, on-going) appearing small vessel ischemic (restriction in blood supply to tissues, causing a shortage of oxygen needed to keep tissue alive) changes.
- At 6:06 PM, her CMP showed her creatinine was 1.66.
- At 6:31 PM, she was discharged with a diagnosis of tremor and generalized weakness. She was provided instructions to take pain medications, drink plenty of fluids to stay hydrated, take her medications as prescribed, return to the ED for any concerning or worsening symptoms and to follow up with the Primary Care Physician (PCP) in three to four days if she showed no signs of improvement.
- In the context of an elevated WBC, all sources of an infection had not been ruled out.
- An appropriate MSE was not conducted as evidenced by no chest x-ray or electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) ordered.
- The provider failed to consider leukocytosis or the prior fall.

The CBC, CMP and UA were not performed which is concerning in the context of abdominal pain, nausea and vomiting in that the presence of other Emergency Medical Conditions were not sufficiently ruled out.

Review of Patient #21's Hospital C medical record showed:
- On 12/04/24 at 1:24 PM, she presented to the ED with dizziness and increased altered mental status (mental functioning ranging from slight confusion to coma).
- At 3:50 PM, her troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.01) was 107 and proBNP (a protein produced by the heart that acts as a signal indicating when the heart is working too hard, often due to heart failure, normal is 0-450), was 8,354.
- At 3:59 PM, she was admitted to inpatient with encephalopathy (damage or disease that affects the brain), pneumonia (infection in the lungs), heart failure (a chronic condition in which the heart cannot pump or fill adequately), parkinsonism (a term that refers to brain conditions that cause slowed movements, rigidity [stiffness] and tremors), dementia (a loss of thinking abilities and memory), convulsions (sudden, violent, irregular movement of a limb or of the body), CKD, bipolar disorder, schizoaffective disorder, early onset Alzheimer's disease (a chronic brain disorder characterized by gradual loss of memory, decline in intellectual ability and deterioration in personality) and disorders of the kidney and ureter.
- At 4:00 PM, a chest x-ray showed left lower lung lobe atelectasis (collapse of part or all of a lung) and less likely a lung contusion (an injury that doesn't break the skin but results in some discoloration).
During an interview on 01/14/25 at 12:00 PM and 01/15/25 at 2:37 PM, Staff U, Physician, stated that a "normal workup" for a patient with a fall, weakness and/or confusion was to evaluate the patient for heart problems, stroke and/or urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). A head CT, CBC, CMP and UA would be ordered, and current medications reviewed. The patient would be evaluated for alcohol and drug use and an examined for bruising, pain and/or injury. Patient #21's elevated WBCs was an "outlier" and no further investigation was completed. Patient #21's current and past CBC and CMP lab results were reviewed for trends and if there was a concern she would have put it in her note. Her CMP reflected CKD; therefore, a nephrology consult was not ordered. Additional imaging for Patient #21 was not ordered.
During an interview on 01/16/25 at 3:35 PM, Staff O, Physician, stated that he expected a radiology (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) work up to locate the cause of the elevated WBCs and the source of the infection. He expected a consult with nephrology for a patient with history of CKD who presented with abnormal labs.
During an interview on 01/16/25 at 1:14 PM, Staff B, CNO, stated that she expected a further work up, including a chest x-ray and cultures (a test to identify bacteria that may cause an infection) to rule out an infection with elevated WBCs. "It was a missed opportunity."


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