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Based on interview, record review and policy review the hospital failed to:
- Conspicuously post signs in the Labor and Delivery (L&D) Unit specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC), and information indicating whether the hospital participated in the Medicaid program (A2402);
- Maintain an accurate Obstetric (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) triage (process of determining the priority of a patient's treatment based on the severity of their condition) log and failed to identify three patients (#17, #19, and #27) and incorrectly logged the disposition of one patient (#8) of eight L&D patient records reviewed. The hospital also failed to provide a complete Emergency Department (ED) log to the survey team in a timely manner. The complete ED log was provided 30 hours after requested (A2405); and
- Provide stabilization treatment with an appropriate discharge including discharge instructions for follow-up care and outpatient treatment recommendations for one patient (#1) of 17 ED patient records reviewed (A2407).

These failed practices had the potential to affect all patients who presented to the ED and OB for triage and treatment of EMCs.

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 EMC)-Compliance," dated 10/17/22, showed:
- When an individual presented or was brought to the hospital requesting treatment of a medical or mental health condition, a physician or advanced practice provider (APP, a licensed medical professional who is not a doctor, but has specialized training to diagnose, treat, and manage many common medical conditions) provided a MSE within the capabilities of the hospital.
- Patients with an EMC received examination and treatment within the capabilities of the staff and hospital to stabilize the EMC.
- An EMC was a medical condition manifesting acute symptoms of sufficient severity that if immediate medical attention was not performed, the health of the person would be in serious jeopardy of a risk of serious impairment of bodily function. Special categories of EMCs included severe pain.
- A patient was deemed stable when no material deterioration of their condition was likely to occur upon discharge or referral for outpatient follow-up.
- Patients treated for an EMC that was resolved by treatment in the ED must have certification in the ED record by the attending physician, APP, or consulted medical specialist that the EMC no longer exists.
- Discharge was defined as the release of a patient from the ED to their place of residence or other non-acute care healthcare facility.

Review of hospital policy titled, "Facility Planning, Design, and Construction Signage," dated 01/19/22, did not contain requirements or direction of EMTALA signage in triage areas.

Although requested, a policy was not provided for EMTALA signage in triage areas.

Review of the hospital's document titled, "ED-Triage-Protocol," dated 07/03/23, showed the following:
- The policy applied to all patients presenting to University of Missouri Health Care (UMHC) ED for care.
- The purpose of the policy was to determine acuity of patients presenting for care.
- Registration of a patient presenting to triage was completed by any staff member by verifying the patient's full name and date of birth.
- Documentation included the patient's chief complaint.
- The policy did not reference maintaining a log of patients who presented to the ED.
- The policy did not reference patients presenting to L&D for triage.

Although requested, a policy on maintaining a log in the ED or L&D was not provided.

Review of the hospital's policy titled "Patient Rights-Patient Right to Refuse Care, Treatment, and Services Against Medical Advice (AMA)-Policy", dated 07/17/23, showed when a patient chooses to leave the hospital AMA, a conversation with the patient regarding risks and benefits of medical care, treatment or services the patient needs in order to participate in health care decisions, the decision to refuse care and leave AMA, including the patient's reason(s) for refusing care and leaving AMA, will be documented in the patient's medical record. The patient will be asked to sign a "Patient Right to Refuse Care, Treatment and Services AMA Form." If the patient refuses to sign the AMA form, a physician or nurse will sign and date the form, indicate the patient refused to sign on the form and placed the form in the patient's medical record.

Review of hospital policy titled, "ED-Department Specific Standards," dated 07/31/23 showed discharge education shall be provided to patients and family prior to leaving the ED. The discharge education shall include a review of the patient's diagnosis and self-care needs, skills and knowledge related to that diagnosis.

Based on observations and interview, the hospital failed to conspicuously post signs in the Labor and Delivery Unit specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC), and information indicating whether the hospital participated in the Medicaid program. These failures had the potential to affect all patients that presented to the Labor and Delivery (L&D) unit for emergency medical treatment. The average number of patients triaged (process of determining the priority of a patient's treatment based on the severity of their condition) in the Women's Health Department from 03/11/24 through 06/10/24 was 1,220 per month. The hospital provided an average L&D triage per month for 06/10/24 through 09/11/24 of 288 per month.

Review of hospital policy titled, "Facility Planning, Design, and Construction Signage," dated 01/19/22, did not contain requirements or direction of 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 EMC) signage in triage areas.

Although requested, a policy was not provided for EMTALA signage in triage areas.

Observation on 09/12/24 at 10:30 AM, in the Labor and Delivery Unit, showed no EMTALA signage at the registration desk, waiting room, or patient rooms.

During an interview on 09/13/24, Staff D, Clinical Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) Manager, stated that she was aware that they did not have the required EMTALA signage posted at the registration desk, waiting room or any of the patient rooms. She stated that the L&D unit had moved two months prior and the hospital was waiting on new signs from the printing company.

Based on observation, interview, record review, and policy review the hospital failed to maintain a complete log of Obstetric (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) patients triaged (process of determining the priority of a patient's treatment based on the severity of their condition) through the Women's Health Unit. The log failed to identify three OB patients (#17, #19, and #27) of eight Women's Health Unit patients records reviewed, was incomplete with date gaps and missing patients and one patient's (#8) disposition was incorrectly identified. The inconsistency of the OB triage logs skewed the average number of OB patients triaged per month provided to the survey team. The hospital also failed to provide a complete Emergency Department (ED) log to the survey team in a timely manner. The log initially provided failed to identify two patients (#13 and #22) of 32 patient medical records reviewed who presented to the hospital ED seeking care from 03/11/24 through 09/11/24. The complete ED log was provided 30 hours after originally requested. This failure had the potential to affect all patients who presented to the ED and OB for treatment of emergency conditions.

Findings included:

Although requested, no policy on maintaining a log in the ED or OB triage patients was provided.

Review of the hospital's document titled, "ED - Triage - Protocol," dated 07/03/23, showed the following:
- The policy applied to all patients presenting to University of Missouri Health Care (UMHC) ED for care.
- The purpose of the policy was to determine acuity of patients presenting for care.
- Registration of a patient presenting to triage was completed by any staff member by verifying the patient's full name and date of birth.
- Documentation included the patient's chief complaint.
- The policy did not reference maintaining a log of patients who presented to the ED.
- The policy did not reference OB patients presenting to the Women's Health Unit for triage.

Review of the hospital's policy titled "Patient Rights - Patient Right to Refuse Care, Treatment, and Services AMA - Policy", dated 07/17/23, showed when a patient chooses to leave the hospital AMA, a conversation with the patient regarding risks and benefits of medical care, treatment or services the patient needs in order to participate in health care decisions, the decision to refuse care and leave AMA, including the patient's reason(s) for refusing care and leaving AMA, will be documented in the patient's medical record along with the time of the patient's departure. The patient will be asked to sign a "Patient Right to Refuse Care, Treatment and Services Against Medical Advice (AMA) Form." If the patient refuses to sign the AMA form, a physician or nurse will sign and date the form, indicate the patient refused to sign on the form and placed the form in the patient's EMR.

Observation on 09/11/24 at 11:45 AM showed electronic logs with folders labeled "WH (Women's Health) ED 2023", "CRMC (Capital Region Medical Center) ED log 2024", "UH (University Health Care) ED log 2023" and "UH ED log 2024" provided to the survey team for selection of a comprising sample of ED patients treated at the hospital. The folder labeled "WH ED 2023" contained two documents titled "WH 6-11-23 to 8-11-23" and "WH 3-11-24 to 6-10-24". The survey team requested logs for every patient who received unscheduled assessments in the hospital from 06/11/23 through 08/11/23 and from 03/11/24 through 09/11/24.

Review of the electronic log titled "WH 3-11-24 to 6-10-24" showed a total number of patients on the log as 3,660, which would average 1,220 per month for the three months. Patients listed on the electronic log showed numerous male patients and patients less than 12 years old.

Review of the hospital document provided on 09/19/24 showed the hospital's Women's Health Unit reported they triaged an average of 288 OB patients per month from 06/10/24 through 09/11/24.

During an observation and subsequent interview on 09/11/24 at 2:30 PM, Staff A, Manager of Risk and Regulatory, stated that the Women's Health Unit moved from an off-campus location to the current location within the hospital in June of 2024. Their newer logs were maintained by a different computer system and providing the log to the survey staff would be delayed. Staff A provided hand-written logs with patient identification stickers obtained from the Women's Health Unit and stated that they were the logs for OB patients triaged from 06/01/24 through 09/11/24.

Review of the hand-written OB logs on 09/11/24 at 2:50 PM showed Patients #17, #19 and #27 were not included. The hand-written log for OB for 09/01/24 through 09/11/24 showed dates with no patient triages between 09/05/24 at 8:07 PM through 09/09/24 at 12:30 PM, indicating missing pages and missing patients within the log. There were 85 patients listed on the hand-written log, 22 patients did not have a disposition indicated.

Review of Patient #17's medical record dated 09/11/24 at 10:14 AM, showed she was a 31-year-old female at 37 weeks gestation (a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days) who presented to OB triage for a labor check. She was discharged home on 09/11/24 at 11:40 AM.

Review of Patient #19's medical record dated 09/11/24 at 11:40 AM, showed she was 20-year-old female at 37 weeks gestation who presented to OB triage with abdominal pain. She was discharged home 09/11/24 at 4:40 PM.

Review of Patient #27's medical record dated 06/25/24 at 1:55 PM, showed she was 27-year-old female at 30 weeks gestation who presented to OB triage for a blood pressure evaluation. She was discharged home on 06/25/24 at 5:30 PM.

During an observation and subsequent interview on 09/11/24 at 4:00 PM, Staff A, Manager of Risk and Regulatory, provided a computer-generated log from the hospital's billing department to the survey team and reported it contained OB triage patients from 06/01/24 through 09/06/24. The computer-generated log did not identify patient names, date of birth, or chief complaint. The patient dispositions were listed. Staff A stated that the hospital met the 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) requirement with the hand-written logs with patient sticker identification.

Review and comparison between the computer-generated log from the hospital's billing department and the hand-written log for OB triage between the dates of 06/11/24 and 06/30/24 showed the log from the hospital's billing department had entries of "OB Triage Facility Fee" for 52 patients with discharge dates the same as their admission date and not located on the hand-written logs, including one patient with a disposition of AMA and one with the disposition of Transferred to Another Facility.

Review and comparison between the computer-generated log from the hospital's billing department and the hand-written log for OB triage between the dates of 09/01/24 and 09/06/24 showed entries "OB Triage Facility Fee" for 15 patients with discharge dates the same as their admission date and not shown on the hand-written logs.

Review of both the OB electronic triage log titled "WH 3-11-24 to 6-10-24" and the computer-generated log from the hospital's billing department, showed Patient #8 was triaged in the Women's Health Unit on 06/03/24 with a disposition of "Left AMA." Patient #8 did not appear on the hand-written log.

Review of Patient #8's medical record dated 06/03/24 at 1:17 AM showed she was a 26-year-old female at 36 weeks gestation who presented to the Women's Health Unit for OB triage with lower back pain and lower abdominal cramping. The medical record showed Patient #8 left the Women's Health Unit without notifying nursing staff and before she was evaluated by the provider. Her disposition was recorded in the medical record as "Left Without Being Seen." There was no documentation of review of risks and benefits and no "Patient Right to Refuse Care, Treatment, and Services AMA Form."

During an interview on 09/12/24 at 11:00 AM, Staff D, OB Clinical Manager, stated that the log of patients triaged in the Women's Health Unit was the hand-written pages with patient stickers attached. She stated that she knew log pages were out of date order and staff had looked for missing pages. She stated that the unit moved from another building to their new location on the hospital campus a few months prior and had not kept up with maintenance of the log.

Review of Patient #22's medical record showed she had presented through the hospital's ED on 09/05/24 and was transferred to the Women's Health Unit for OB evaluation.

During an interview on 09/12/24 at 1:30 PM, Staff S, Physician Assistant (PA, a type of mid-level health care that can serve as a principal healthcare provider), stated that Patient #13 was triaged in the ED on 08/02/24 and transferred to the University of Missouri Psychiatric (relating to mental illness) Center (MUPC) for evaluation.

Review of the original ED log provided to the survey team showed Patient #13 did not appear on the log for an ED visit on 08/02/24 and Patient #22 did not appear on the log for an ED visit on 9/05/24.

Observation on 09/12/24 at 3:45 PM showed the hospital provided a second electronic ED log. The second log showed visits by Patient #13 on 08/02/24 and Patient #22 on 09/05/24.

During an interview on 09/12/24 at 2:20 PM, Staff R, Service Line Specialist, stated that the electronic log for the ED originally provided to the survey team was generated with a filter that removed patients who were low-risk behavioral health and immediately moved to MUPC and those greater than 20 weeks gestation and immediately moved to the Women's Health Unit for OB triage. The filter on the electronic log was not discovered until the survey team identified visits for Patients #13 and #22 did not appear on the electronic logs originally provided.

Based on interview, record review, and policy review, the hospital failed to provide discharged patients with discharge instructions identifying conditions stabilized and the plan for appropriate follow-up care for one emergency department (ED) patient (Patient #1) out of 17 patient records reviewed. This failure could affect all patients discharged from the ED.

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)-Compliance," dated 10/17/22, showed:
- Discharge was defined as the release of a patient from the ED to their place of residence or other non-acute care healthcare facility.
- An EMC was a medical condition manifesting acute symptoms that the absence of immediate medical attention could reasonably be expected to result in placing the person in jeopardy, serious impairment of bodily function, or dysfunction of a bodily organ or part.
- A special category under EMC was severe pain.
- Stabilizing treatment included removing the risk of deteriorate to the patient's medical condition prior to discharge.
- A patient was deemed stable when no material deterioration was likely to occur from or during discharge.
- Patients treated for an EMC that was resolved by treatment in the ED must have certification in the ED record by the attending physician, advanced practice professional, or consulted medical specialist, that the EMC no longer exists.

Review of hospital policy titled, "ED -Department Specific Standards," dated 07/31/23 showed:
- Discharge education shall be provided to patients and family prior to leaving the ED.
- Discharge education shall include a review of the patient's diagnosis and self-care needs, skills and knowledge related to that diagnosis.
- Signs and symptoms that require notification of a provider and who to call should be provided.
- The hospital/provider call back numbers should be provided to the patient.

Review of hospital policy titled, "Medical Record Service - Provider Content of the Medical Record: Document Information required based on visit type," dated 8/29/22 showed all emergency visits should include the final disposition, condition of patient and instructions for follow-up.

Review of Patient #1's medical record showed:
- He was a 49-year-old male who presented to the ED on 06/25/23 with a past medical history of a closed head injury and seizure disorder (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness) who lived with caregivers in an assisted living facility (ALF).
- He was brought to the ED via ambulance with right arm pain following a seizure and fall.
- A physical assessment was completed showing he had swelling, limited range of motion, discomfort, and pain of the right arm.
- A series of x-rays (tests that creates pictures of the structures inside the body-particularly bones) were performed showing a displaced fracture of the right humerus (a long bone in the arm that runs from the shoulder to the elbow)
- Staff GG, Orthopedic (medical specialty dealing with bones) Physician, was consulted, and the treatment plan included a support sling for the arm and to follow up as an outpatient within the next few days.
- Documentation showed he was educated verbally by Staff X, Registered Nurse (RN) on the treatment plan and follow up with family present.
-The discharge instructions provided to the patient and the ALF included the recommended treatment plan for his seizure diagnosis.
- Documentation failed to include documentation of the broken humerus, follow-up instructions, and pain management. The record did not show ED staff called the ALF staff and reported findings and recommendations during Patient #1's ED visit.

Review of Patient #1's second medical record showed:
- He was a 49-year-old male who presented to the ED on 06/27/23 with right arm pain after he slept on his arm "wrong" and had difficulty with his balance since a fall with right arm fracture.
- He was evaluated in the ED on 06/25/23 for right arm pain and a fracture was identified. His right arm was placed in a support sling and he was discharged home with instructions to follow-up with orthopedics and neurology (neuro, relating to or affecting the nervous system) as an outpatient.
- Patient #1 was admitted to the hospital on 06/27/23 for orthopedic and neurologic evaluation. Conservative management of his right arm fracture was followed until he underwent surgical correction on 07/19/23.
- Patient #1 was discharged from the hospital on 08/02/23.

During a telephone interview on 09/18/24 at 3:22 PM, Staff X, RN, stated that she could not recall if she had called report to anyone at the ALF. She stated that if a patient had a consult in the ED that required follow-up, but nothing was listed on the discharge instructions, she would have the provider enter the correct information. The nurses did not have the ability to change the discharge information.