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Based on policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#12) of 31 Emergency Department (ED) records reviewed from 10/30/24 through 03/31/25. 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).

Findings included:

Review of the hospital's policy titled, "EMTALA," dated 01/12/24, showed appropriate MSEs were provided to individuals who requested examinations or treatment. MSEs consisted of an assessment and ancillary tests based on the patient's presenting symptoms or chief complaint, as necessary, to determine the presence of absence of an EMC. Assessments could be a brief history and physical or could require complex ancillary studies and monitoring, such as an EKG. If EMCs were discovered as the result of an MSE, the patient was provided stabilizing treatment until the EMC resolved or appropriate transfer was facilitated. Individuals were stabilized when their condition was assured, within reasonable medical probability, not to materially deteriorate; or when the treating physician determined, within reasonable clinical confidence, that the EMC was resolved.

Please refer to 2406 for further details.

Based on policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#12) of 31 Emergency Department (ED) records reviewed from 10/30/24 through 03/31/25. 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).

Findings included:

Review of the hospital's policy titled, "EMTALA," dated 01/12/24, showed appropriate MSEs were provided to individuals who requested examinations or treatment. MSEs consisted of an assessment and ancillary tests based on the patient's presenting symptoms or chief complaint, as necessary to determine the presence of absence of an EMC. Assessments could be a brief history and physical or could require complex ancillary studies and monitoring, such as an EKG. If EMCs were discovered as the result of an MSE, the patient was provided stabilizing treatment until the EMC resolved or appropriate transfer was facilitated. Individuals were stabilized when their condition was assured, within reasonable medical probability, not to materially deteriorate; or when the treating physician determined, within reasonable clinical confidence, that the EMC was resolved.

Review of Patient #12's ambulance report, dated 01/16/25, showed paramedics noted abdominal distention and pain throughout his abdomen, sides and lower back. His vital signs (VS, measurements of the body's most basic functions) were within normal limits (WNL), except his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80), which ranged from 209/113 to 220/119. He was transported to Cox Medical Center Branson (CMCB).

Review of Patient #12's medical record, dated 01/16/25, showed:
- At 6:45 PM, a 53-year-old man presented to the ED with complaint of constipation, abdominal pain and nausea (a feeling of sickness with an urge to vomit). His pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was eight.
- His medical history included kidney failure with weekly dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) treatments.
- The physician ordered blood tests, an abdominal x-ray (test that creates pictures of the structures inside the body-particularly bones) and a computed tomography (CT, a combination of x-rays and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) of his abdomen. CT results indicated liquid stool, then a large amount of hard stool, within the colon and rectum. No small bowel obstruction (a partial or complete blockage in the small or large intestine that prevents food, fluid, or stool from passing through) was present.
- At 9:45 PM, VS showed tachycardia (abnormally rapid heart rate, greater than 100 beats per minute [bpm]). His heart rate was 102 bpm.
- At 9:48 PM, he received ondansetron (medication used to treat nausea) and hydromorphone (medication used to treat severe pain).
- At 10:30 PM, his heart rate was 118 bpm, his blood pressure was 260/126.
- At 10:45 PM, he received hydromorphone and hydralazine (medication used to treat high blood pressure).
- At 11:11 PM, he received prochlorperazine (medication used to treat nausea).
- At 11:18 PM, his final pain score was six.
- At 11:30 PM, his heart rate was 140 bpm, his blood pressure was 184/97.
- On 01/17/25 at 00:20 AM, he received diltiazem (medication used to lower blood pressure and to reduce the workload of the heart).
- At 00:57 AM, a physician order for discharge was placed.
- At 1:20 AM, staff removed stool manually and an enema was performed.
- At 1:28 AM, he received lactulose (medication used to treat constipation).
- At 1:30 AM, nursing documentation indicated that Patient #12 was allowed to remain at the hospital until his dialysis appointment later that morning.
- At 1:45 AM, his heart rate was 124 bpm, his blood pressure was 119/112.
- At 2:31 AM, he received clonidine (medication used to lower high blood pressure and heart rate).
- At 4:30 AM, the patient slept.
- At 5:45 AM, final VS showed his heart rate was 120 bpm.
- At 6:04 AM, discharge instructions were provided. He was to return if conditions worsened or persisted. It was recommended that he follow-up with a physician. Instruction included tips on the management of nausea and constipation symptoms. He was escorted to his dialysis appointment.

Review of Patient #12's ambulance report dated 01/17/25, showed he was transported to Hospital B, and complained of an elevated heart rate, that he contributed to the potassium chloride he received for hypokalemia (low potassium level in the blood) while in the CMCB ED. His VS were WNL, except tachycardia which ranged from 119 to 121 bpm. An electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) recorded a regular heart rhythm. He was transported to Hospital B.

Review of Patient #12's Hospital B medical record, dated 01/17/25, showed:
- At 10:27 PM, he arrived in the ED, via EMS, with history of no bowel movement for five days. He was previously seen at CMCB and stated that nothing was done, nothing helped.
- Medical records from CMCB indicated that he had a CT of the abdomen that suggested constipation. He was manually disimpacted, received a soap suds enema and was unable to have bowel movement since then. His abdominal pain and distention increased.
- At 10:47 PM, lab results indicated increased Troponin I High Sensitivity (a type of blood test that measures whether or not a person is experiencing, or may soon experience, a heart attack where normal is 0-15). His lab result was 600.
- On 01/18/25 at 12:53 PM, a rapid response (a changing situation that requires more staff to address the current needs of the patient) was called during his dialysis treatment for irregular heart rhythms of supraventricular tachycardia (abnormal heart rhythm in which the upper chambers of the heart beat very quickly) and ventricular tachycardia (a condition in which the lower chambers of the heart [ventricles] beat very quickly).
- On 01/18/25 at 3:13 AM, an abdominal CT was completed for abdominal pain and distention. The CT was compared to the CT completed on 01/16/25. Findings indicated a bowel obstruction.
- At 4:21 AM, an abdominal x-ray was completed that indicated a bowel obstruction was present.
- He had a nasogastric tube (NG, soft, flexible tube inserted through the nose and into the stomach to remove stomach contents, or to instill drugs, liquids, or liquid food) placed and was admitted to the hospital.

During an interview on 04/02/25 at 2:18 PM, Staff R, ED Medical Director, stated that exams for constipation included physical assessments, history, blood tests and CT imaging. Treatment included manual removal of stool, enemas, and medications for pain, nausea and fluid management. Physicians reassessed patient symptoms during treatment. Patients were discharged with instructions on managing symptoms of constipation; in most cases patients continued with outpatient treatment options as they were rarely admitted for constipation.

During an interview on 04/02/25 at 12:20 PM, Staff Q, Physician, stated the protocol for constipated patients included blood tests, CT images and rectal exams. Treatment took hours and included fluid management, manual removal of stool, enemas and medications. Improvement usually took days, therefore patients continued treatment after discharge.

During an interview on 03/31/25 at 3:30 PM, Staff M, RN, stated that at times, providers would complete an MSE on patients before the order set testing resulted.

During an interview on 04/02/25 at 12:13 PM, Staff P, RN, stated that Patient #12's pain improved. He used the commode and was more comfortable after treatment. Patients were not always cured in the ED.