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800 S ASH ST

NEVADA, MO 64772

COMPLIANCE WITH 489.24

Tag No.: A2400

MEDICAL SCREENING EXAM

Tag No.: A2406

Based on 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 five (# 1, #8, #13, #18, and #23) of 31 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Emergency Department Scope of Services," revised 11/21/24, showed:
- An EMC was defined as a condition that is a danger to the patient and could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future. An EMC includes, but is not limited to undiagnosed acute pain, substance abuse symptoms, and psychiatric (relating to mental illness) conditions, such as depression (extreme sadness that doesn't go away), insomnia (difficulty falling asleep or staying asleep), suicidal/suicidal ideation (SI, thoughts of causing one's own death) or attempt, dissociative state (mental health conditions that involve a loss of connection between thoughts, memories, feelings and identity) and inability to comprehend danger or care for self.
- Initial assessments should include the chief complaint and the assignment of the Emergency Severity Index (ESI, a triage level scale used in emergency departments to rank patients by acuity, from level 1 [most urgent] to level 5 [least urgent] and vital signs (VS, measurements of the body's most basic functions) to be completed and a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). Height, weight and a focused physical exam related to the chief complaint.
- Reassessments for those areas of complaint should be completed after interventions performed.
- Suicide risk assessment, allergies, home medications, past medical and surgical history, and infectious disease screening are to be obtained.
- ED services include triage (process of determining the priority of a patient's treatment based on the severity of their condition), initial and ongoing assessment by a Registered Nurse (RN), a MSE provides all necessary testing and on-call services withing the capability of the hospital to reach a diagnosis.
- Federal law requires that all necessary definitive treatment will be administered to the patient and only maintenance care can be referred to a physician's office.
- An MSE includes monitoring of VS, pain level, stabilization and treatment of any EMC, including protection from self-harm and screening for all types of abuse. This includes the use of ancillary departments, including social services, circulation stabilization, medication administration and diagnostic imaging.
- Discharge and follow up instructions should be completed with every patient. A patient who may be at reasonably at risk to deteriorate is unstable and may not be discharged.

Review of the hospital's policy titled, "Left Without Being Seen (LWBS)/Against Medical Advice (AMA)/Elopement (when a patient makes an intentional, unauthorized departure from a medical facility)," revised 08/20/2024, showed:
- If multiple patients present at the same time, they are triaged including an initial assessment and information gathering.
- LWBS is defined as a patient that stays long enough to speak with registration and be placed on the log but leaves before having their complaint and initial VS documented or prior to receiving an MSE to determine if an EMC exists.
- If a patient leaves prior to triage, every effort should be made to determine the reason for leaving and they should be informed of the benefits for remaining, and the risks of leaving the ED. A Refusal of MSE form should be signed and witnessed by the ED staff, becoming part of the medical record. If the patient refuses to sign the form, that should be documented.
- AMA is defined as a patient that refuses to consent to an MSE and withdraws their request for examination or treatment. A Release of Responsibility for Discharge form should be completed and/or refusal to sign documented, becoming part of the medical record.
- Patients that are intoxicated (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs), hypoglycemic (low blood sugar), have head trauma, are in postictal (pertaining to the period follow a seizure) state, experienced a drug overdose, dementia (a loss of thinking abilities and memory), psychosis (a serious mental illness characterized by defective or lost contact with reality), or experiencing acute (sudden onset) stress are considered to lack decision making capacity and are not able to leave AMA.
- For patients lacking decision making capacity, with imminent threat to life, limb, or health, immediate treatment may be rendered without consent.
- Patients at risk for elopement must have measures put into place to ensure their safety. They should be visible from the nurses' station at all times and/or have one to one care. Law enforcement should be notified if a patient elopes with intoxication, an altered mental status, or is having a behavioral health crisis. Staff should complete an incident report.

Review of hospital's policy titled, "Pain Management, Assessment and Reassessment," revised 01/19/23, showed:
- All patients should have a prompt and effective assessment and management of pain.
- The RN is responsible for completing a pain assessment that includes the location, nature of pain, onset and duration, type, intensity and quality.
- The appropriate pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) should be used.
- Reassessments should be completed within 60 minutes of the administration of pain medication or pain intervention, and with each new complaint of pain.

Review of hospital's policy titled, "Charges and Documentation - Emergency Department," revised 05/30/23, showed that ED staff are responsible documenting all care rendered to each patient during their ED visit.

Review of hospital policy titled, "Management of the Emotional Ill Patient," revised 11/24/24, showed:
- Patients expressing SI or those that have attempted suicide, must be placed under constant surveillance by a staff member or law enforcement officer to prevent attempts to harm self. Their clothing should be removed, and they should be searched for weapons or items that could cause harm.
- Patients should be assessed for thoughts of suicide, paranoia (excessive suspiciousness without adequate cause), depression, visual and/or auditory hallucinations (seeing or hearing things which are not there). If they are deemed to be suicidal, homicidal, have severe psychosis, or are agitated, a sitter will be provided.
- Patients must receive psychiatric and medical screenings to determine the absence of an EMC prior to discharge. The on-call psychiatrist and ED provider must discuss all findings, including diagnostic testing, and agree on disposition of the patient, prior to discharge. If they do not agree, a face-to-face evaluation by the psychiatrist may be required.

Review of Patient #1's medical record, dated 09/27/25, showed:
- At 8:51 PM, a 27-year-old female presented to the ED with complaints of abdominal pain that she had tolerated for one week but had become sharp and severe that day.
- Her VS were within normal limits, and she rated her pain, in her left lower abdominal quadrant, at a nine. Her pain radiated to her left lower back and side.
- A physical assessment showed her abdomen was tender and non-distended.
- Laboratory testing included a pregnancy test, urinalysis (a laboratory examination of a person's urine), complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) and a Lipase (an enzyme produced by the pancreas which the body uses to break down fats, normal is 10-99) levels. Her results were unremarkable.
- At 9:26 PM, intravenous (IV, in the vein) fluids and IV Toradol (a nonsteroidal anti-inflammatory drug [NSAID] that is used to treat moderately severe pain and inflammation) were administered.
- At 9:56 PM, a computed tomography (CT, a combination of x-rays [tests that create pictures of the structures inside of the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan of her abdomen and pelvis (area of the body below the abdomen) without contrast were completed.
- At 10:01 PM, her CT results indicated prominent inflammatory changes extending through the pelvis with fullness in the right ovary. A pelvic ultrasound (a test that uses sound waves to create images of structures within the body) was recommended to assess the etiology (cause) of the pelvic inflammatory changes. The inflammatory changes could represent pelvic inflammatory disease (PID, a serious infection of a woman's reproductive organs). The appendix (a small tube-shaped part that is joined to the intestines on the right side of the intestines) was not definitively seen however no dilated tubular structure was seen to suggest appendicitis (inflammation of an organ located in the lower right abdomen). A follow-up CT with contrast was recommended if the pelvic US did not correlate with the inflammatory changes in the pelvis which appeared centered around the uterus (within a woman's pelvis where a fetus develops and grows). No abnormalities were seen within the kidneys.
- No additional tests were ordered or performed.
- No follow up pain assessments or VS were documented.
- At 10:17 PM, physician documentation showed that the abdominal CT showed no acute findings, her laboratory tests were within normal limits and upon reassessment she had slept and felt much better.
At 10:38 PM, she was discharged with instructions to follow-up with her primary care provider.
- No prescriptions were provided.
- There was no documentation that the CT results and recommendations were discussed with her.

During an interview on 10/01/25 at 8:15 AM, Staff G, Quality Director, stated he was unable to locate a specific policy related to incidental findings with radiology tests.

During a telephone interview on 10/08/25 at 9:30 AM, Staff K, ED Director, stated that the provider should notify the patient if there was an abnormality on their CT scan. Nursing should be aware to ensure additional testing has been completed if there was an EMC. Nursing educates the patients and assists them with the needed follow up. For patients with primary care physicians, the results would be sent to that provider. VS, including pain assessments, should be obtained according to hospital policy and based on the patient's acuity level. They are to be obtained after any intervention, within 60 minutes of any pain medication administration, and documented, with a final set obtained prior to discharge. At times nursing prints out the VS and place a patient sticker on them to be scanned into the medical record.

During a telephone interview on 10/08/25 at 10:30 AM, Staff J, Chief Nursing Officer (CNO), stated that the provider should notify patients of incidental findings and recommendations obtained from radiological (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) exams. VS, along with pain assessments, should be obtained and documented, within 60 minutes of pain medication administration, prior to discharge, and per policy. It was not acceptable for nurses to print a copy of the VS, label them, and then scan them into the medical record, unless the computer system was down.

During a telephone interview on 10/08/25 at 4:30 PM, Staff C, ED Medical Director, stated that he expected the physician to discuss CT results with the patients and to document those conversations. Patient #1 should have been prescribed antibiotics and instructed to return the next day for the US if it was not obtained during her initial visit. Nursing staff should obtain and document VS and pain reassessments.

During a telephone interview on 10/09/25 at 8:15 AM, Staff P, ED Physician, was unable to recall Patient #1. When provided the CT results, he stated that US testing was not available during her ED visit. US was only available Monday through Friday during the day shift hours. Any incidental findings based on CT results could be followed up as an outpatient. Patient #1 did not have signs or symptoms of PID. She had no vaginal discharge. He stated that the CT findings were reviewed with the patient. She already had an appointment and was going to follow-up with her gynecologist (a medical professional which deals with the functions and diseases specific to women and the reproductive system). The conversation was not documented in the medical record.

Review of Patient #8's medical record, dated 04/03/25, showed:
- At 12:54 PM, a 69-year-old male presented to the ED with a snake bite.
- He had been seen at an urgent care center but was told to go to the ED to be evaluated. His VS were obtained with a blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) of 177/82, HR of 77, T of 97.8, RR of 18, SPo2 of 99%, and a pain scale rate of three.
- Documentation indicated a few small abrasions/puncture wounds in the skin from the bite. The snake was determined to be non-venomous.
- His past medical history, surgical history, family history, social history and current medications were not documented.
- At 1:04 PM, a tetanus injection was administered, and antibiotic ointment was applied to the puncture sites.
- At 1:28 PM, he was discharged. No additional VS were documented.

Review of Patient #13's medical record, dated 05/26/25, showed:
- At 9:20 AM, a 41-year-old female presented to the ED with domestic abuse and back pain radiating up to her shoulders. Her spouse had assaulted her, throwing her around the room and up against the wall. Her pain scale rating was an eight. She filed a police report.
- Triage documentation indicated there was no suspected abuse.
- Her past medical history, surgical history, social history and current medications were not documented.
- At 9:34 AM, an IM injection of Toradol 30 mg was administered for pain.
- At 10:39 AM, a CT of the lumbar and thoracic spines resulted with no acute findings.
- At 11:05 AM, she was discharged with the diagnosis of myalgia (muscle aches and pain). She was instructed to follow-up with her primary care physician.
- No follow-up pain assessment, discharge VS, social service referrals, or interventions or resources for domestic abuse were documented as being offered or presented.
- There was no documentation within the medical record indicating that she was being discharged to a safe environment.

During an interview on 10/08/25 at 9:30 AM, Staff K, ED Manager, the nurse was responsible for obtaining past medical history, surgical history, and current medications as part of triage. All patients provided care in the ED should have discharge VS completed and documented prior to discharge. All patients that present to the ED are screened for abuse. If abuse has been identified, there should be documentation that the patient was offered information related to the available resources and a referral for social services. If the patient declined those interventions, the nurse should document that they were offered but refused. Social services were available for all patients that present to the ED with abuse.

During an interview on 10/08/25 at 10:30 AM, Staff J, CNO, stated that she expected nursing staff to follow hospital policy by obtaining all information including past medical history, surgical history, family history, social history, and any current medications during triage. Failure to obtain that information could trigger an EMTALA violation. That information should always be obtained. Per hospital policy, all patients being discharged from the ED should have a set of discharge VS and a pain assessment completed and documented prior to discharge.

During an interview on 10/08/25 at 4:30 PM, Staff C, MD, stated past medical history, surgical history, social history and current medications should have been obtained and documented per hospital policy. Nursing was responsible for obtaining all the information and ensuring it was documented during the triage process. Once a physician writes orders for discharge, the nurse should obtain VS prior to discharge.

Review of Patient #18's medical record, dated 05/03/25, showed:
- At 1:49 PM, a 28-year-old male presented to the ED accompanied by law enforcement with a complaint of SI. Signed affidavits (a written statement confirmed by oath, for use as evidence in court) indicated he wanted to kill himself but did not have a plan.
- At 2:09 PM, VS were obtained along with laboratory tests including a CBC, CMP, acetaminophen (pain medication, also used to reduce fever) level, UA, and urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications).
- At 2:30 PM, a psychiatric consult was ordered and an IV was started.
- ED physician documentation stated that Patient #18 came in with a complaint of depression. He had intermittent thoughts of harming himself over the last year but had never acted on it. He was not currently having suicidal thoughts.
- At 4:08 PM, his IV was removed.
- At 4:19 PM, he was discharged with instructions to follow-up with his PCP and given a list of local resources.
- There was no behavioral health documentation or documentation of any conversations or phone calls with the on-call psychiatrist in the medical record.
- Patient #18 was not placed on one to one (1:1, continuous visual contact with close physical proximity) observation, nor was there documentation regarding a search of his person for any weapons or objects that could result in self-harm.
- His VS were not obtained and documented prior to discharge.

Review of a hospital document titled, "Affidavit (a written statement confirmed by oath, for use as evidence in court)," dated 05/03/25 at 1:49 PM, showed a police officer documented that Patient #18 came to the calm realization he wanted to commit suicide. Patient #18 told the officer directly that he wanted to kill himself, but did not have a plan.

During an interview on 10/08/25 at 10:30 AM, Staff J, CNO, stated staff should pay attention when an affidavit was presented by law enforcement. All BH patients in the ED must have a consultation with psychiatry prior to being discharged. Psychiatric consultations always available 24 hours per day. If there was an affidavit and the physician wanted to discharge a psychiatric patient, a face-to face must be completed with the psychiatrist on call prior to the discharge. Nurses should notify the house supervisor or charge nurse if there was an issue of a patient having an affidavit and a psychiatrist not being consulted. "I reviewed that particular chart after it was requested. We failed to follow our policy for patients that present with SI. A psychiatric provider was not contacted for Patient #18 prior to being discharged."

During an interview on 10/08/25 at 4:30 PM, Staff C, ED Medical Director, stated ED physicians do not always call the on-call psychiatrist. He was not involved in hospital policy reviews but was consulted at times. He was not aware that hospital policy required a consult be done with psychiatrist prior to the discharging a patient with SI.

Review of Patient's #23 medical record, dated 05/02/25, showed:
- At 6:07 PM, an 84-year-old male presented to the ED after a fall with an altered mental status.
- He lived alone, had a history of dementia, was not making sense, and family was concerned that he may have mixed up his medications.
- Staff Q, ED Physician, documented that Patient #23 had been seen on 04/27/25 for similar symptoms. He had been checked out a few days ago and there was no need to reevaluate him. He was alert and oriented times two (he knew who he was and where he was).
- At 7:30 PM, he was discharged with instructions to follow up with his primary care provider for medication management and encouraged to be more active in his community.
- There was no documentation of his current medications, or any assessments related to the fall reported during triage.

During an interview on 10/08/25 at 4:30 PM, Staff C, ED Medical Director, stated that no matter how many times a patient returned to the ED for similar symptoms a complete MSE and stabilization should be performed. All obligations must be fulfilled for EMTALA.

51509

HospitalInspections.org

NEVADA REGIONAL MEDICAL CENTER

COMPLIANCE WITH 489.24

MEDICAL SCREENING EXAM