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Based on record review and interview, the hospital failed to comply with the provider agreement under 42 CFR §489.24, which outlines the special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the Emergency Medical Treatment and Labor Act (EMTALA) requirements for 1 of 1 patient (Patient #1). Patient #1 presented to the emergency department (ED) on March 18, 2024, with a chief complaint of abdominal pain, nausea, and vomiting. These symptoms occurred in the context of a motor vehicle accident in February 2024 that resulted in significant injuries, including pelvic fractures, rib fractures, and a splenic laceration, which had required surgical intervention.


Cross refer to Tag: A 2406

Based on the record review and interview, the facility's emergency department physician failed to provide an appropriate medical screening examination (MSE) within the hospital's (1 of 1 patient) capability.

Finding include:

A review of the medical record for Patient #1 revealed the following;

Patient #1 was a 36-year-old female who presented to the Emergency Department (ED) on 03/18/24 at 2:15 PM, with complaints of 4 days of epigastric abdominal pain and vomiting. Patient #1 had been in a motor vehicle accident that had occurred in February 2024 and the patient had undergone a Cesarean section. The motor vehicle accident resulted in significant injuries, including pelvic fractures, rib fractures, and splenic laceration, which required surgical intervention.

A review of Physician #10 provider notes revealed the following:

"Provider note on 3/18/2024 at 3:49 PM:
Patient C/O onset N/V and epigastric pain x 4 days, reports recent MVC she had x I month ago ... DX of left of fractured pelvis with screw placement, rib fractures, and a spleen laceration. Pain to epigastric is 10/10, sharp, constant. The patient is unable to hold down oral intake. Denies any blood in vomit or stool. The last bowel movement was today but very small. The patient is unable to walk yet and reports she can't start physical therapy until 2 weeks from now. PRN Norco at home for pain."

"Respiratory: CT A BIL
Cardiovascular: RRR; Normal S2, S2
Gastrointestinal: Abdomen son, non-tender, positive bowel sounds. "State has not had a "good bowel movement x 6 days". Bowel sounds hyperactive, borborygmi (a rumbling or gurgling noise made by the movement of fluid and gas in the intestines)."

A review of the CT (computed tomography) revealed the following:

"CT Angio Chest, CT abdomen/pelvis with contrast was completed on 3/18/2024, at 5:45 PM Impression: "Large left diaphragmatic hernia containing the majority of the stomach, that extends into the major fissure and causes atelectasis of the left lower lobe."

The patient was treated in the Emergency room with anti-emetics and intravenous fluid for her presenting symptoms. Patient #1 had not had a normal bowel movement in 6 days. The patient did not receive gastric decompression in the form of a Nasal gastric or oral gastric tube. There was no documentation that the patient could tolerate oral fluids during the emergency visit, which would have lowered clinical suspicion for an obstruction.

A review of the on-call log for the surgery consult revealed that Surgeon #11 was on call but there was no documentation of a surgical consult.

Patient #1 was discharged home on 3/18/2024 at 7:21 PM with instructions for GERD (Gastroesophageal Reflux Disease) and to follow up with her primary care physician and return if symptoms worsen. There was documentation about the herniation of the Gastrointestinal tract into the chest cavity.


Patient #1 continued to have symptoms and went to another facility on 03/19/2024 at 12:40 PM less than 24 hours from discharge from the first facility. Patient #1 was diagnosed with Gastrointestinal tract obstruction and was found to have herniation of the Gastrointestinal tract into the chest cavity and diaphragmatic rupture. Patient #1 was taken to the Operating room for surgical intervention.

An interview with Patient#1 revealed that she went to the hospital because it was close to her home and the patient was "vomiting a lot" and it "hurt to breathe and move''. The patient was vomiting about every 30 minutes. The physician told me my stomach was shoved up underneath my lung and discharged me and told me to follow up with my primary doctor. I couldn't have gotten any worse than just dying. Vomiting continued at home. The facility gave me oral medication in the emergency room, and I ended up throwing it all back up. The facility did not offer any help to me, so I went home and tried to do what they said, which was to call my doctor. I just couldn't wait any longer and had to seek treatment in Tyler where they took good care of me after my wreck in February." The patient confirmed she had emergent surgery and was now recovering at home.