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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 exam (MSE) for three patients (#6, #7 and #35) out of 35 Emergency Department (ED) records reviewed from April 2021 through October 2021. 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, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment). The hospital's average monthly ED census over the past six months was 1,782.

Findings included:

1. Review of the hospital's policy titled, "Medical Screening Examination (MSE)," dated 08/2021, showed that patients who present to the ED for unscheduled procedures or evaluation, should receive an MSE by a provider, along with any ancillary services routinely available to the ED. Patients should not be denied evaluation, screening, testing, treatment or stabilization on the basis of their presenting complaint, condition, or lack of physician on medical staff of this hospital.

2. Patient #6, a 17 year old male, presented to the ED with his mother on 06/14/21 at 6:44 PM, for suicidal ideations (SI, thoughts of causing one's own death). According to interview with the patient's mother, she brought the patient to the ED because he was belligerent, threatening, and had destructive behavior. The patient was not triaged or placed in a room under the supervision of staff for safety, but was placed in a waiting room after the patient's mother was informed there would be a three to four hour wait before the patient would be seen. The patient's mother was also informed that the patient could not be admitted to the adolescent psychiatric unit because their unit was full, although review of of the adolescent unit staffing sheets showed there were eight inpatients with a capacity to admit up to 15. The patient's mother reported that she waited in the ED for approximately 20 minutes before she left with the patient and transported him to the ED at Hospital B (acute care hospital). Hospital B records showed that the patient arrived to the ED at 8:11 PM, a psychiatric consult was completed and found the patient was homicidal (thoughts of killing others) and determined he was at imminent risk of harm to himself or others. Arrangements were made to transfer the patient by ambulance for inpatient psychiatric care at Hospital E (psychiatric hospital) where he was admitted with major depressive disorder, suicidal risk and homicidal thoughts.

3. Patient #7, a 69 year old male, presented to the ED with his wife on 09/06/21 at 7:52 AM, for shortness of breath, inability to sleep and requesting dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer work properly). He reported he had been traveling from out of state, and when he became short of breath, he believed it indicated he needed dialysis. His heart rate was documented at 40 beats per minutes (low, normal is 60-100), and he reported shortness of breath to the nurse, however no tests were ordered and he was not seen by a physician. During interview with the patient and his wife, they reported that while the patient was in an examination room in the ED, his wife waited in the waiting room. Both were informed by hospital staff that the hospital could not do dialysis in the ED, and the wife was told to take the patient to Hospital B, and provided her with the phone number to Hospital B. The patient's wife called and spoke with staff at Hospital B, who informed her that is was not her responsibility to make arrangements for the patient to be transferred. A Unit Secretary from Hospital B stated during interview, that after she spoke with the patient's wife, she spoke to ED staff at Missouri Delta and informed them that the patient should be formally transferred. At 9:52 PM, nurse documentation in the ED record showed "the only thing we could be able to do" was run labs and tests on the patient, and that she had explained to the patient's wife that dialysis was not completed except during "absolute emergency." The patient stated that lab work and tests were never discussed with him, and that he was asked to sign paperwork so he would not be charged for the visit. The record showed that the patient signed a release for leaving the ED prior to medical screening and departed. Hospital B's ED record showed that the patient arrived with his wife to the ED at 11:15 AM, requesting dialysis and complaining of shortness of breath and trouble sleeping. He was evaluated by a physician, diagnostic tests were completed, and the patient was discharged after the MSE was completed.

4. Patient #35, a 12 year old female, presented with her mother to the ED on 09/07/21 at 9:37 PM, with complaints of self harm. The ED record showed that the patient voiced she wanted to kill herself after she was sent to detention. When the patient was asked about suicide risk factors, the patient confirmed that she wished to be dead, had thoughts about how she might commit suicide, and had previously planned or prepared to end her life. The Nurse Practitioner (NP) documented that the patient's mother reported the Division of Family Services had instructed her to take the patient to the ED for a psychiatric evaluation, but the NP informed the patient's mother that the hospital's role was to provide a medical clearance examination, and that they did not have a psychiatrist available to evaluate the patient. The medical record showed that the plan was to consult Behavioral Health Group D (contracted inpatient psychiatric staff and providers) for an evaluation, but the patient's mother signed the patient out against medical advice, indicated that she would contact Behavioral Health Group D herself, and left with the patient.

Please refer to 2406 for further detail.

Based on interview, record review, and policy review the hospital failed to maintain an accurate central log for patients presenting to the emergency department (ED) for care. The log failed to accurately document the disposition of one patient (#35) of 35 ED records reviewed from the ED logs from April 2021 through October 2021. The hospital's average monthly ED census over the past six months was 1,782.

Findings included:

1. Review of the ED log dated 09/07/21, showed that Patient #35 presented to the ED on 09/07/21 at 9:37 PM with the complaint listed as statement of self harm and her disposition was logged as eloped.

Review of Patient #35's ED medical record showed that she was a 12 year old female that had presented to the ED on 09/07/21 at 9:37 PM with the complaint listed as statement of self harm. The patient and her mother's contact and insurance information was documented. Patient #35 did complete triage. Per the triage note, Patient #35 had stated that she wanted to kill herself after having been sent to detention. She denied any suicidal thoughts or a plan of action. Her disposition had been set to eloped. Per the provider notes, the Nurse Practitioner (NP), documented that the patient's mother had told her that Division of Family Services (DFS) had instructed mom to bring Patient #35 to the ED for a Psychiatric Evaluation. The NP documented that she told the patient's mom that the hospital's role was to complete a medical clearance exam and that the hospital did not have a psychiatrist available to evaluate the patient. The mother felt that Patient #35 was being manipulative and refused to consent to an admission in the adolescent psychiatric unit. There was an AMA form dated 09/07/21, signed by two staff members.

Patient #35 had been identified on the ED log dated as an eloped psychiatric patient, but left AMA with her guardian.

During an interview on 10/28/21 at 11:33 AM, Staff BB, Chief of Staff, stated that she would expect the ED log to have accurate information documented and to be able to identify the disposition of any patient entered.

The overall failure of the hospital to accurately enter patient information, including an accurate name and disposition, made it difficult to identify whether or not patients received an MSE, stabilizing treatment, or were transferred appropriately. This failure has the potential to effect all patients that present to the hospital ED.


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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 exam (MSE) for three patients (#6, #7 and #35) out of 35 Emergency Department (ED) records reviewed from April 2021 through October 2021. 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, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment). The hospital's average monthly ED census over the past six months was 1,782.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA); Transfer of Emergency Room Patients to Another Facility," dated 08/2021, showed that:
- The hospital must provide an MSE to any individual who presents to the ED and requests an examination.
- The hospital cannot to refuse an examination or treatment for a patient with an EMC.
- The appropriate means of stabilization for the patient should be implemented.

Review of the hospital's policy titled, "Appropriate Medical Screening (MSE)," dated 08/2021, showed that patients who present to the ED and request treatment, or had a request made on their behalf, should receive an appropriate MSE. If the patient was determined to have an EMC based on the MSE, the patient would be provided any necessary stabilizing treatment, admitted, or transferred to an appropriate level of care.

Review of the hospital's policy titled, "Medical Screening Examination (MSE)," dated 08/2021, showed that patients who present to the ED for unscheduled procedures or evaluation, should receive an MSE by a provider, along with any ancillary services routinely available to the ED. Patients should not be denied evaluation, screening, testing, treatment or stabilization on the basis of their presenting complaint, condition, or lack of physician on medical staff of this hospital.

Review of the hospital's policy titled, "Patients Influenced by Drugs, Alcohol, Emotionally Ill or Difficult to Manage," dated 10/04/21, directed staff to:
- Ensure that patients who are emotionally ill or difficult to manage, are placed in a safe environment.
- Complete the SAFE-T/Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) Suicide (thoughts of causing one's own death) Risk Assessment for all ED patients being evaluated or treated for behavioral health conditions.
- Place a sitter with patients at risk of suicide to maintain one to one observation at all times, and to document this on the Close Observation Flow Sheet.

Review of the hospital's policy titled, "Close Observation/Suicide Assessment," dated 12/02/19, directed staff to:
- Complete the SAFE-T/C-SSRS for all patients at risk of self harm.
- Place those individuals on continuous one on one (1:1, continuous visual contact with close physical proximity) monitoring.
- Immediately arrange for a sitter.
- Ensure that 1:1 documentation be completed every 15 minutes.
- Continue suicide precautions until the physician or Mental Health Specialist discontinues them.

Although requested, the hospital failed to provide a written contract or agreement with Behavioral Health Group C (a group of mental health providers used by the hospital to provide psychiatric intake evaluations of their ED patients).

2. Review of Patient #6's ED record showed that he was a 17 year old male who presented to the ED on 06/14/21 at 6:44 PM, with the complaint listed as "suicidal." The patient's insurance, and his mother's contact information were documented. There was no other documentation in the medical record.

During an interview on 10/25/21 at 2:05 PM and 10/27/21 at 10:28 AM, Staff G, ED Manager, stated that all psychiatric patients would be placed in an exam room with a sitter for 1:1 observation, as soon as a patient was recognized to have psychiatric concerns. However, Patient #6 was not triaged or placed on observation for SI, and the hospital had not followed-up with the patient's mother to ensure the patient was safe.

During an interview on 11/01/21 at 3:00 PM, Patient #6's mother stated that she had accompanied her son to Missouri Delta Medical Center ED on 06/14/21. She signed him into the ED to have him evaluated for belligerent, threatening, and destructive behavior. The registration staff member informed her that the wait was three to four hours to be seen. She was then advised that the adolescent psychiatric unit at Missouri Delta was full and that her son would not be able to be admitted there. She was instructed to wait in the waiting room, which she felt was odd considering her son's psychiatric complaint. She stated that he was not placed under staff supervision, that the ED was very busy, multiple people were coughing in the waiting room, and she was concerned about contracting COVID-19 (highly contagious, and sometimes fatal, virus). She waited for about 20 minutes, and when no other patients had been called back to the ED exam rooms, she left and took her son to Hospital B (acute care hospital). Her son was seen in Hospital B's ED and immediately placed on close observation, provided a psychiatric evaluation and determined to need inpatient psychiatric treatment for homicidal ideations.

Review of the hospital's staffing sheets dated 06/14/21 showed that the adolescent psychiatric unit census for Missouri Delta was eight patients, with the capacity to admit up to 15 patients.

Review of Hospital B's ED record for Patient #6, showed that the patient presented on 06/14/21 at 8:11 PM, with complaints of having thoughts of harming others, specifically his boss. A psychiatric consult was completed and showed that the patient was homicidal, determined to be at imminent risk of harm to self or others, and arrangements were made to transfer the patient for inpatient psychiatric care to Hospital E (inpatient psychiatric hospital). The patient was transported to Hospital E by ambulance on 06/15/21 at 3:08 PM.

Review of the medical record from Hospital E showed that the patient arrived on 06/15/21 at 7:38 PM for inpatient psychiatric care. He was admitted with a diagnosis of major depressive disorder (a long period of feeling worried or empty with a loss of interest in activities once enjoyed) with a suicide (to cause one's own death) risk, and actively having homicidal thoughts.

3. Review of the ED record for Patient #7 dated 09/06/21, showed that the patient was registered at 7:52 AM for shortness of breath, inability to sleep, and felt he needed dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions). The patient's chief complaint was that he was traveling from out of state, had dialysis four days prior, and was short of breath. His pulse was documented as 40 beats per minutes (low, normal is 60-100). A nursing assessment documented at 8:38 AM, showed that the patient reported he was having trouble breathing, but no vital signs were documented at that time, and no tests were ordered. A nurse progress note entered at 9:52 AM by Staff H, Registered Nurse (RN), showed that the patient's wife wanted to leave when the nurse explained that dialysis was not completed in the ED except during an "absolute emergency," and that "the only thing we could be able to do" was run labs and tests on the patient. At 9:51 AM, the patient signed a release for leaving the ED prior to medical screening, and departed. There were no lab tests ordered, and there was no documentation that the patient refused to have lab tests completed.

During an interview on 10/27/21 at 3:08 PM, Patient #7 stated that he came to the ED at Missouri Delta Medical Center on 09/06/21 because he felt short of breath, which indicated to him that he needed dialysis. He lived in Michigan, but had been traveling. He stated that when he checked in to the ED, the staff put him in a room and his wife could not stay with him. He waited for almost three hours, and then the nurse told him that they did not do dialysis at the hospital. Patient #7 stated that no one talked to him about labs or tests. One of the ED nurses provided his wife with a telephone number for another hospital located about 30 minutes away, and he was told that he could sign a paper so he "wouldn't get charged" for the ED visit.

During an interview on 10/27/21 at 3:12 PM, Patient #7's wife stated that while her husband was in the ED, a female nurse came to the waiting room where she waited, and provided her with a phone number for Hospital B. The nurse told her that they were not equipped for dialysis in Missouri Delta's ED, and to "take him to [city where Hospital B is located]." She stated that she called the phone number she was provided, talked with a nurse at Hospital B, who informed her that it was not the patient's nor his family's responsibility to make transfer arrangements from one hospital to another. The nurse from Hospital B spoke with one of the ED staff members over the phone to discuss Patient #7's potential transfer to Hospital B. Patient #7 signed paperwork and they left the ED.

During an interview on 10/26/21 at 4:03 PM, Staff S, RN, stated that when she triaged Patient #7, he reported he had missed a couple of dialysis visits that week, complained of being short of breath, and requested dialysis. She stated that the patient's vital signs were stable and he did not exhibit shortness of breath on assessment. She stated that she heard the patient's primary nurse, Staff H, discuss with the patient the need to have blood drawn to determine whether or not dialysis was needed. She stated that what she heard in the conversation was that the patient refused to have the blood drawn and wanted to have dialysis done without labs. She confirmed that the ED had the capability to do emergent dialysis if necessary, based on on-call availability.

During an interview on 10/26/21 at 1:30 PM, Staff H, RN, stated that when the patient presented, he reported that he had missed his dialysis sessions that week and needed to have dialysis done. He did not display symptoms during triage or the primary nurse's assessment. She told him that labs and tests would be necessary to determine the emergent need for dialysis, but the patient responded that he did not want to have labs done. She discussed the patient with the ED physician and the ED physician told her to tell the patient he would need to sign out AMA if he would not have the lab work performed. She did not feel comfortable asking the patient to sign out AMA, so she asked her charge nurse for guidance. She stated that the charge nurse, Staff G, spoke with the patient and his wife and soon after that discussion, the patient signed paperwork to leave. She was not present when Staff G spoke with the patient or his wife.

During an interview of 10/26/21 at 2:06 PM, Staff G, ED Nurse Manager (functioned as charge nurse during Patient #7's presentation), stated he did not recall Patient #7, however, a patient would not be told that they could not be seen in the ED or that the hospital would not do dialysis.

During an interview on 10/27/21 at 1:29 PM, Staff Y, ED Physician, stated that vital signs alone were not an indication of needing emergent dialysis, and required an assessment of lab values and overall condition to determine if emergent dialysis was indicated. Staff Y denied that he encouraged the nurse to have the patient sign out AMA and confirmed that if a patient needed emergent dialysis, the hospital would admit the patient. If a patient desired to leave AMA, the physician would speak with the patient, document the conversation in the physician notes, and the
patient would be asked to sign a form which indicated they were leaving AMA.

During an interview on 10/27/21 at 8:15 AM, Staff B, President, stated that the hospital had two nephrologists (a specialty physician that deals with the physiology and diseases of the kidneys) privileged to treat patients, but only provided care to their established patients.

During an interview on 10/25/21 at 2:23 PM, Staff K, RN, stated that dialysis could be performed in the ED if the patient was established with one of the two nephrologists privileged at Missouri Delta. If the patient was not an established patient of the nephrologist and required dialysis, they would be transferred to another hospital via an ambulance.

During an interview on 11/22/21 at 11:09 AM, Staff DD, Unit Secretary at Hospital B, stated that during a telephone conversation, Patient #7's wife informed her that she received the phone number for Hospital B from a nurse in the ED at Missouri Delta, who told them dialysis was not done in their ED, and requested they contact Hospital B's ED. Staff DD stated she spoke with a nurse (name unknown) from Missouri Delta, who stated they were sending the patient to Hospital B. Staff DD advised the nurse that the patient should be appropriately transferred, but the patient was not transferred, and just "showed up."

During an interview on 11/22/21 at 11:35 AM, Staff EE, Emergency Physician at Hospital B stated that he recalled treating Patient #7 in the ED. Patient #7 and his wife told him that they were seen at Missouri Delta, placed in a room, and never saw a provider. They stated that blood tests, electrocardiogram (EKG - test that checks for problems with electrical activity in the heart) and a chest x-ray were not offered or completed. The patient and his wife reported that a nurse at Missouri Delta gave them the phone number for Hospital B, told them that they did not perform dialysis in the ED, and that they should go to Hospital B for treatment.

4. Review of Patient #35's ED medical record showed that she was a 12 year old female who had presented to the ED on 09/07/21 at 9:37 PM, with the complaint listed as statement of self harm. The triage note showed that Patient #35 had voiced that she wanted to kill herself after having been sent to detention. The SAFE-T/C-SSRS form showed that when the patient was asked about suicide risk factors, the patient confirmed that she wished to be dead, had thoughts about how she might commit suicide, and had previously planned or prepared to end her life. The Nurse Practitioner (NP) documented that the patient's mother reported that the Division of Family Services (DFS) had instructed her to take Patient #35 to the ED for a psychiatric evaluation. The NP documented that she told the patient's mom that the hospital's role was to complete a medical clearance exam and that the hospital did not have a psychiatrist available to evaluate the patient. At 10:09 PM, the plan was to consult Behavioral Health Group D (the hospital's contracted inpatient psychiatric staff and psychiatrists) to evaluate the patient. At 11:07 PM, the patient's mother signed that the patient would be leaving AMA, and at 11:15 PM, a nurse documented that the patient left AMA and that the mother would call Behavioral Health Group D herself. There was no documentation regarding a psychiatric evaluation within the medical record.

During an interview on 10/26/21 at 2:00 PM, Staff G, ED Manager, stated that there was not a psychiatrist on-call for the ED, that the inpatient psychiatrists did not provide on-call coverage to the ED and the hospital did not utilize tele-psych. For adolescents and geriatrics, they would utilize contracted providers, Behavioral Health Group D, however, they only provided psychiatric care for the hospital's inpatient adolescent and geriatric psychiatric units, and did not provide ED coverage.

During an interview on 10/27/21 at 8:15 AM, Staff B, President, stated that the Behavioral Health Group D psychiatric providers were contracted staff. They provided and managed the psychiatric treatment for the adolescent and geriatric psychiatric units within the hospital, but did not provide on-call coverage or responded to the ED for psychiatric evaluations.

Review of the hospital's staffing sheets dated 09/07/21 showed that the adolescent psychiatric unit for Missouri Delta was 10 patients, with the capacity to admit up to 15 patients.


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