HospitalInspections.org

Based on policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#21) of 21 Emergency Department (ED) records reviewed from 05/07/25 through 11/06/25. 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, "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)," revised 12/13/23, showed the following:
- Any individual who presented to the ED requesting treatment would be provided a MSE to determine whether the individual was experiencing an EMC.
- An EMC was a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to any bodily functions or serious dysfunction of any bodily organ or part.
- An MSE was an examination sufficient to reasonably indicate the presence or absence of an EMC for an individual. The MSE would be provided within the capability of the hospital's ED including ancillary services routinely available to the ED.
- Any individual experiencing an EMC would be stabilized prior to transfer or discharge.
- Stabilization was when an EMC was managed such that no material deterioration of the condition was likely within reasonable medical probability to result from or occur during the transfer of the individual from a facility.

Please refer to 2406 for further details.

Based on interview, record review and policy review the hospital failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#21) of 21 Emergency Department (ED) records reviewed from 05/07/25 through 11/06/25. These failed practices 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 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)," revised 12/13/23, showed the following:
- Any individual who presented to the ED requesting treatment would be provided a MSE to determine whether the individual was experiencing an EMC.
- An EMC was a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to any bodily functions or serious dysfunction of any bodily organ or part.
- A MSE was an examination sufficient to reasonably indicate the presence or absence of an EMC for an individual. The MSE would be provided within the capability of the hospital's ED including ancillary services routinely available to the ED.
- Any individual experiencing an EMC would be stabilized prior to transfer or discharge.
- Stabilization was when an EMC was managed such that no material deterioration of the condition was likely within reasonable medical probability to result from or occur during the transfer of the individual from a facility.

Review of the Patient #21's Hospital C medical record, dated 10/16/25, showed:
- At 6:24 PM, she presented to the ED with a complaint of a fall off a scooter onto concrete the previous day. She landed on her buttocks and did not strike her head or have any loss of consciousness. She reported concern of frequent concussions in the past and was worried the whiplash (an injury caused by a sudden jerk or jolt to the head) caused headaches and dizziness or another concussion.
- She was seen earlier that day by a chiropractor who adjusted her neck which made it "lock up even more." She stated her buttocks was sore, but she did not feel like anything was broken. She was able to sit without difficulty.
- Her blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was slightly elevated, but her vital signs (VS, measurements of the body's most basic functions) were otherwise normal.
- At 7:47 PM, she was seen by the physician. He noted she described a sensation of her head being "not right," similar to whiplash with dizziness. Her symptoms worsened after a deep tissue neck massage. She also reported having difficulty focusing, felt overwhelmed, and was unable to complete tasks such as homework or reading. She was concerned about her ability to function normally and was uncertain about her capacity to drive home.
- Her physical exam showed she appeared distressed with signs of anxiety and feeling overwhelmed. Her neurological (neuro, relating to or affecting the nervous system) exam showed she reported dizziness and difficulty focusing but was otherwise normal. Her other body systems were within normal limits.
- Differential diagnoses included concussion related to her history of multiple concussions, and anxiety. He advised rest, avoiding activities that could exacerbate symptoms, and follow-up with her primary care physician or a mental health professional.
- No additional testing or treatments were completed.
- The discharging nurse documented that he and the charge nurse had an extensive conversation with the patient going over her discharge instructions attempting to address all of her concerns. The patient was reluctant to be discharged, she wanted instead to stay in the ED room with the lights turned down. She was educated that she had been medically cleared from the ED and was to follow up with a neurologist (a physician who specializes in the care of the nervous system) and rest in dark rooms. She was capable of ambulating to the ED and drove herself. She was taken to the ED waiting room and instructed to drive herself home or use her phone to have someone come get her.
- At 8:58 PM, she was discharged.

Review of the Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) report, dated 10/17/25 showed:
- EMS was called for a sick person with an altered level of consciousness (the state of being fully alert, aware, oriented, and responsive to the environment).
- EMS arrived at 2:59 PM and found Patient #21 lying on an exam table in a college clinic. She was a 31-year-old woman, and the clinic provider reported that she had been in several times over the past few days after having an accident on a scooter. She did not hit her head in the accident, but she had a history of a traumatic brain injury (TBI, an injury in how the brain works) and was concerned about her current symptoms.
- She was alert and oriented times four (A&O x4, a person is oriented to person, place, time, and situation), her Glascow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) was 15, and her stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) assessment was normal.
- She complained of dizziness and headache for several days, otherwise her physical exam was normal.
- Her VS were stable with a slightly elevated BP.
- An electrocardiogram (EKG, test that records the electrical signals from the heart to check for different heart conditions) showed a normal heart rhythm.
- An intravenous catheter (IV, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) was placed, but no additional treatment was given during transport.

Review of Patient #21's medical record, dated 10/17/25, showed:
- At 3:34 PM, she arrived via EMS with a complaint of head pain and light sensitivity. She reported a fall the previous week and her pain was worsening after seeing a chiropractor (a healthcare professional who specializes in the diagnosis and treatment of musculoskeletal disorders, primarily focusing on the spine).
- Staff P, ED Physician, documented that his first encounter with the patient was at 4:26 PM. She was having significant difficulty articulating the nature of her complaint and she refused to take off her sunglasses for evaluation.
- A review of systems was positive for dizziness and headaches. A psychiatric/behavioral examination was negative. No detailed neurological or psychiatric assessments were documented.
- Her physical examination showed normal body systems.
- Her BP was slightly elevated at 131/98; her other VS were normal, and she was A&O x4.
- Staff P documented that he had an extensive discussion over discharge instructions and attempted to address any concerns the patient might have had. She was reluctant to be discharged and wanted to stay in the ED room with the lights turned down.
- At 6:26 PM, the clinical impressions listed included, "anxiety states," and "concussion without loss of consciousness."
- Staff O, RN, documented that she gave the patient her discharge instructions and answered the patient's questions. However, the patient was stating her questions were not answered. When Staff O asked her what questions weren't answered, she hid under her blanket and did not answer. She refused to leave, and security was called to escort her out.
- The discharge instructions stated she should follow up with her primary care physician and included generic resources and information about pain and BP management.
- At 6:35 PM, the police were noted to be at the bedside.
- At 6:42 PM, Staff O noted Patient #21 was ambulatory and left the ED with the police.
- No ancillary testing was completed and no medications were administered.

Review of the St. Charles Police report dated 10/17/25, showed the officer responded to a complaint that a patient was refusing to leave the hospital after she had been discharged. He told the patient that she needed to leave, but she became argumentative. She curled up into a ball while lying on the ED bed and pulled a blanket over her body. He continued attempting to ask her to leave voluntarily but she continued to refuse. He grabbed the blanket, and she became combative. Security staff assisted with physically removing her from the bed. She then became dead weight and actively resisted being removed by trying to grab onto the bedding. She was moved to the ground on her stomach, her arm was moved behind her back. He used a closed fist to strike her back which was successful in unclenching her other arm and he was able to apply handcuffs. She was taken to the police car. Upon arrival for processing, she refused to get out of the vehicle. Additional personnel were utilized to escort her into a jail cell. She was given two municipal court summons for trespassing and resisting arrest.

During an interview on 11/11/25 at 9:00 AM, Staff P, ED Physician, stated that he recalled Patient #21. His impression was that her symptoms were primarily anxiety related. When he first attempted to assess her and discuss her symptoms she wouldn't answer his questions. She refused to remove her sunglasses, had a hoodie up and covered her head with a blanket. He offered to come back later and reassess her. When he came back in for his second attempt to assess her, he spent a long time with her trying to determine the nature of her complaints. He was able to do a thorough neurological exam, and she did not have any deficits. She was not altered; she was fully alert and oriented and understood where she was and what he was asking. She did not appear visibly to be in pain or distress and had no signs of injury. She could not verbalize any specific complaint that he could investigate. She reported a headache, but she also said she had chronic daily headaches, and this was not different from her baseline. She denied nausea or vomiting. He was not aware if the college clinic had sent any communication about their concerns for the patient's symptoms or condition. However, he was able to see that the patient had been seen in Hospital C's ED the day before. He reviewed that encounter and found that her presentation was similar and there were no concerning findings at that time. Staff P stated that he offered her multiple opportunities to relay more information. She did not request any specific testing or treatment, she just refused to leave the ED room without communicating any medical concerns.

During an interview on 11/11/25 at 8:35 AM, Staff O, RN, stated she remembered Patient #21. She was her primary nurse. Patient #21 had autism but was capable of verbalizing normally. When Staff O tried to talk to the patient she would go under a blanket and would not answer questions. EMS gave report to triage, but did not have much additional information to supply. She stated that work ups for headache complaints were based on the provider's impression and there were no standard treatment plans. Treatment was based on the individual's presentation. Patient #21 did not seem to be in any visible pain or distress. She did not appear dizzy or unsteady when she ambulated. Staff O attempted to give her discharge instructions, but the patient refused and went under the blanket. She tried to ask her what questions she had but she would not answer. Patient #21 did not ask to speak with the doctor again and would not verbalize what she wanted. She was escorted out by the police. She was fully oriented and had no signs of an altered mental status.