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Based on policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#2 and #4) and to arrange an appropriate transfer for one patient (#3) of 30 Emergency Department (ED) records reviewed.

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) BJC East," published 10/01/24, showed:
- An EMC means a medical condition manifesting itself by acute (sudden onset) symptoms of
sufficient severity (including severe pain) 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.
- Any individual requesting emergency care or treatment must receive an appropriate MSE, beyond medical triage (process of determining the priority of a patient's treatment based on the severity of their condition), by qualified medical personnel, including ancillary services routinely available and within the hospital's capacity and capability, to determine if an EMC exists. All requests for examination or treatment must be honored.
- If an EMC is determined to exist, the hospital must provide either further examination or treatment to stabilize the EMC within its capacity or transfer the individual to an appropriate medical facility.
- No patient will be discharged or transferred without a MSE.

Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they 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 two patients (#2 and #4) of 30 Emergency Department (ED).

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 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) BJC East," published 10/01/24, showed:
- An EMC means a medical condition manifesting itself by acute (sudden onset) symptoms of
sufficient severity (including severe pain) 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.
- When an individual comes to the ED and requests emergency care or
treatment the hospital must provide an appropriate MSE, beyond
medical triage (process of determining the priority of a patient's treatment based on the severity of their condition), by qualified medical personnel.
- The MSE must be within the hospital's capacity and capability and include ancillary services routinely available to determine if an EMC exists.
- The hospital must honor all requests for examination or treatment.
- The hospital must utilize the routinely available ancillary services to conduct the medical screening
examination.
- No patient will be discharged or transferred without a medical screening examination.

Review of Patient #4's medical record dated 07/20/25, showed:
- He was a 23-year-old with no past medical history.
- On 047/20/25 at 5:54 PM, he presented to the ED with a complaint of a chemical exposure. He stated he "breathed in" a small amount of freon on 07/17/25, and since that time had muscle weakness and body aches.
- He had no past medical history.
- At 8:00 PM, his Vital signs (VS, measurements of the body's most basic functions: Blood pressure (BP) normal between 90/60 and 120/80; heartbeats (HR) normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; and body temperature (T) normal 97.8 to 99 degrees) were BP-130/77, HR-87, RR-16 and T-98.5o Fahrenheit (F). His oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) was 100%.
- At 6:02 PM, 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 seven of 10.
- At 6:21 PM, a nursing musculoskeletal (bones, muscles, joints, tendons and ligaments which all work together to provide the body with support, protection, and movement)
assessment showed he had generalized weakness.
- At 6:25 PM, the provider note showed he had fatigue (weakness or tiredness), muscles aches and pains and a headache. The body aches and headache developed a day after the freon exposure.
- The exposure was discussed with poison control and there was no concern and stated he was outdoors and did not exhibit signs or symptoms of freon toxicity.
- The differential diagnoses included freon inhalation, viral infection and overuse syndrome.
- At 6:32 PM, Staff L, Physician, electronically signed the record after Staff S, PA.
- At 6:35 PM, he was discharged home with instructions to treat his symptoms with over-the-counter medications and to call poison control if he had concerning symptoms.

Review of Patient #4's Hospital B medical record showed:
- On 07/20/25 at 11:41 PM, he presented to the ED with a complaint of generalized body aches since 7/16/25, he reported not being able to pick up a gallon jug or open a car door. He reported no appetite. He had burnt freon his him in the face the same day the symptoms started.
- The history and physical note showed he was seen at Parkland Health Center; conservative treatment was recommended, and they did not believe his symptoms were related to freon exposure.
- His platelets (cell fragments in the blood that initiate clot formation and stop or prevent bleeding, normal is 150 to 400) were 138.
- His creatinine kinase (CK, a blood test that shows if there is damage to your heart, skeletal muscles or brain, normal is 39 to 308) was 1,930.
- His C-reactive protein (CRP, a blood test to check for inflammation in the body, normal is less than 5) was 6.6.
- His aspartate aminotransferase (AST, an enzyme that is found mostly in the liver, normal is less than 41) was 83.
- He was admitted with a diagnosis of mild rhabdomyolysis (serious syndrome due to muscle injury where the muscles break down).

During a telephone interview on 09/10/25 at 12:35 PM, Staff L, Physician, stated that she did not care for Patient #4, she did review the chart prior to the interview. She signed off on the medical record because Staff S, PA, asked for her help contacting poison control. She believed the patient had worked out too hard. When asked her professional opinion regarding any additional work up related to the patient's symptoms not related to his freon exposure, she declined to answer.

During an interview on 09/09/25 at 12:00 PM, Staff O, Clinical Excellence Director, stated that Patient #4's mother filed a grievance (a formal written or verbal complaint related to care or service that cannot be resolved immediately at the bedside) on behalf of her son but she was not on the Health Insurance Portability and Accountability Act (HIPAA, provides privacy standards and protects patients' medical records against unauthorized access) form for release of information. She alleged that the hospital failed to listen to her son, and he was admitted to Hospital B after he was discharged. The son never returned her call to obtain consent to release information to his mother. The chart review showed Patient #4 was ruled out for dehydration (a condition caused by excessive loss of water from the body) and was not seen at Hospital B until 12 hours after he was discharged.
Although requested, Staff S, Physician Assistant (PA, a type of mid-level health care that can serve as a principal healthcare provider), she was not available.

Review of Patient #2's medical record, dated 02/26/25, showed:
- At 8:25 PM, he was a 64-year-old who presented to the ED with left side/rib pain from a gastrostomy tube (G-tube, soft, flexible tube inserted through the skin of the abdomen and into the stomach). He appeared to be in moderate discomfort.
- No past medical history was recorded.
- At 8:43 PM, his vital signs (VS, measurements of the body's most basic functions: blood pressure (BP) normal between 90/60 and 120/80; heartbeats (HR) normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; and body temperature (T) normal 97.8 to 99 degrees) were BP-166/85, HR-72, RR-18 and T-97.7o Fahrenheit (F). His oxygen saturation (SAO2, measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) was 100%.
- At 8:44 PM, 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 of 10.
- At 9:07 PM, a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) was within normal limits.
- At 9:24 PM, a comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) showed an alkaline phosphatase (an enzyme responsible for bone growth and repair, normal is 40 to 130) was 158 and a creatinine (blood test that shows how the kidney is functioning, normal is 0.8 to 1.3) was 0.59.
- At 9:38 PM, an electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed normal sinus rhythm (NSR, rhythm of a healthy heart).
- At 9:41 PM, a nursing skin assessment showed the percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person's abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) insertion site was red and inflamed.
- At 9:51 PM, a Troponin T High Sensitivity (a blood test that measure whether or not a person is experiencing a heart attack, normal result is between 0 and 22) was 13.
- At 11:10 PM, a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan showed the stomach was significantly distended with fluid with a prominent area of narrowing at the duodenal bulb (portion of the small intestine, right after the stomach) with suspicion for a small amount of free air (air or gas is present in a part of the body where it should not be, often indicates a perforated organ). A surgical consultation was recommended.
- At 11:17 PM, a phone consult was placed to Hospital B's access line.
- At 11:52 PM, the ED Provider note showed the patient was an inmate at the local prison system and the prison system used Hospital B's facility for inpatient care.
- On 07/27/25 at 12:02 AM, intravenous (IV, in the vein) antibiotics and protonix (medication used to treat too much acid in the stomach) were administered and a chest x-ray showed no evidence of an acute (sudden onset) process.
- At 12:07 AM, the ED Provider note showed Staff M, Physician, spoke with the prison's on-call physician and the on-call physician recommended to transfer the patient to Hospital B as they had contracts with Hospital B.
- At 12:34 AM, Hospital B's Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients) wanted to speak to Hospital B's ED physician about a possible ED to ED transfer as the patient may have had a perforated viscus (a medical emergency where a hole or tear forms in the wall of a hollow organ in the abdomen).
- At 12:37 AM, a lactate test (test that measures level of lactic acid [an acid produced in muscle tissue cells and red blood cells during strenuous exercise], normal level is 0.7-2) was 1.3.
- At 1:09 AM, Hospital B's hospitalist accepted the patient as a direct admission. The EMTALA transfer form showed the reason for transfer was a higher level of specialty services unavailable at Hospital A.
- At 4:10 AM, he was discharged.

During a telephone interview on 09/09/25 at 2:18 PM, Staff M, Physician, stated that when Patient #2 was determined to have an EMC he contacted the prison system physician and received a request to transfer the patient to Hospital B because Hospital B had a contract with the prison system. When Staff M was questioned as to why the EMTALA transfer form showed the reason for transfer was to higher level of specialty services unavailable at the facility, he responded, "that was a mistake." He clicked the wrong box; he should have clicked transfer per request.



Surveyor: Gray, Emily





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Based on interview, record review and policy review, the hospital failed to arrange an appropriate transfer for one patient (#3) out of 30 Emergency Department (ED) records reviewed.

This failed practice had the potential to cause harm to all patients who presented seeking care in 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): BJC EAST," published 10/01/24, showed:
- When an individual is determined to have an emergency medical condition (EMC), the hospital will provide necessary examination and treatment to stabilize the patient within the hospital's capabilities and capacity; and follow established protocols for appropriate transfer of the patient to another medical facility if indicated or if requested by the patient.
- If an EMC is determined to exist, the hospital must provide either further examination or treatment to stabilize the EMC within its capacity or transfer the individual to an appropriate medical facility.
- An appropriate transfer is a transfer in which the transferring hospital provided medical treatment within its capacity that minimizes the risks to the individual's health and one in which the receiving facility has available space and qualified personnel for the treatment of the individual.

Review of the hospital's document titled, "No Doc Cardiology July 2025," showed Staff Q, Physician, was on-call 07/24/25 through 07/27/25.

Review of the hospital's document titled, "General Surgery July 2025," showed Staff R, Physician, was on-call 07/24/25 through 07/27/25.

Review of Patient #3's medical record, dated 07/24/25, showed:
- At 6:15 PM, a 73-year-old male presented to the ED with chest pain that began at approximately 1:30 PM, while he was sitting in a chair. He reported the pain started very sharp and had eased up some; he denied nausea.
- His past medical history included coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing) and high blood pressure.
- His past surgical history included four cardiac stent placements (A tiny tube placed into an artery, a vein, or another structure such as the ureter [tube that carries urine] to hold the structure open) over 10 years ago.
- At 6:21 PM, his vital signs (VS, measurements of the body's most basic functions) were within normal limits, except for an elevated blood pressure (BP, normal between 90/60 and 120/80) of 165/82. 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 four of 10.
- At 6:24 PM, his electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed sinus rhythm (SR, rhythm of a healthy heart) with a first-degree atrioventricular (AV) block (a mild type of heart arrhythmia).
- At 6:29 PM, the nursing cardiac assessment showed within defined limits. Symptoms included chest pressure (pain across both sides of his lower chest). He rated the pressure at a four of 10.
- At 6:34 PM, the nursing gastrointestinal assessment showed within defined limits. His symptoms included nausea.
- At 6:57 PM, his Troponin T High Sensitivity (a blood test that measure whether or not a person is experiencing a heart attack, normal result is between 0 and 22) was 19.
- At 7:13 PM, the ED provider documentation indicated they were waiting to talk to the Patient #3's cardiologist (a physician that specializes in the care of your heart and blood vessels). At that time, based on the fact that he had not had a cardiac catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions) for quite some time, his chest pain and his risk factors, the plan for his disposition was to be to the care of his established cardiologist. Hand off was provided to the oncoming physician, advising that they were waiting for a return call from the patient's cardiologist.
- At 7:19 PM, his alkaline phosphatase (an enzyme responsible for bone growth and repair, normal is 40 to 130) was elevated, at 158.
- At 8:47 PM, he reported increased pressure in his right lower chest and rated the pressure at a four of 10, with his pain increasing with palpation (using one's hands to assess the body).
- At 8:51 PM, morphine (an opioid pain medication) was given intravenous push (IVP, to manually administer a dose of medication through a tube into a vein) for pain.
- At 8:57 PM, a repeat EKG showed SR with a first-degree AV block.
- At 9:01 PM, his Troponin T High Sensitivity two-hour was 15, his Troponin T delta (the change in high-sensitivity troponin T levels between two blood tests. An increase of more than 6 over three to four hours is consistent with acute [sudden onset] heart attack) was -4 and the interpretation was insignificant.
- At 9:10 PM and 9:48 PM, his pain scale assessment scores were two of 10.
- At 9:12 PM, a phone call consult order was placed with the patient's cardiologist. There was no documentation of a conversation with the cardiologist.
- At 10:25 PM, a phone call consult was placed to Hospital B's access line.
- At 10:46 PM, his Troponin T High Sensitivity four-hour was 14, his Troponin T delta was -5 and the interpretation was equivocal.
- At 11:45 PM, Hospital B's access line responded, Patient #3 was accepted by the Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients).
- On 07/25/25 at 1:42 AM, a change in status note showed Patient #3 asked for pain and nausea medication.
- At 1:48 AM, he vomited and complained of severe abdominal pain.
- At 4:05 AM, his pain scale assessment was nine of 10.
- At 4:49 AM, a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan of his abdomen and pelvis showed
cholecystolithiasis (gallstones [pebble-like pieces of digestive fluid that form within the gallbladder]) that suggested an acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the bile duct [tiny canals that connect some of the organs in your digestive system]) and recommended a gallbladder ultrasound (a test that uses sound waves to create images of structures within the body) for further evaluation.
- At 5:08 AM, an order was placed for a gallbladder ultrasound and nursing report was provided to the Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) team.
- At 5:10 AM, Staff L documented EMS was there to pick up the patient for transport. The plan was to update the admission team regarding the CT findings and the need for an ultrasound to confirm or rule out acute cholecystitis.
- At 5:16 AM, he was discharged.

Review of Patient #3's Hospital B medical record, dated 07/25/25, showed:
- At 6:19 AM, he arrived as an elective admission transferred from Hospital A.
- At 7:55 AM, the history and physical showed he presented in transfer from Hospital A ostensibly for a cardiology evaluation despite the fact that the originating facility had interventional cardiology. He reported acute onset right upper quadrant abdominal pain which was worse with palpation.
- His assessment/plan included a workup for acute cholecystitis to include an ultrasound and general surgery consult.
- There was no suspicion for an acute coronary syndrome (ACS, any condition brought on by a sudden reduction or blockage of blood flow to the heart) or angina (chest pain caused by low blood flow to the heart).
- At 8:48 AM, a cardiology documentation showed Patient #3 was transferred due to supposed chest pain. The patient stated that palpation to his right upper abdominal quadrant caused pain, it was the same pain he experienced at Hospital A, it was different than any time he had "heart problems." He had no cardiac contraindications to surgery. He was to follow up with cardiology as an outpatient.
- At 1:28 PM, an operative report showed he had a cholecystectomy (surgical removal of the gallbladder; a small organ that stores liquid called bile and helps your body break down food).
- On 07/26/25 at 11:30 AM, he was discharged home.

During an interview on 09/09/25 at 2:43 PM, Staff N, Physician, stated that Patient #3 presented with "severe chest pain" and had not had a cardiac catheterization in 10 years. His work up looked "okay, at the time." A normal EKG and troponin did not mean the chest pain was not heart related. A cardiologist may have chosen to perform a cardiac catheterization because of the patient's chest pain and history. She attempted to contact the patient's cardiologist but never spoke to him/her. She usually documented a formal consult in the medical record. The goal would be to document the conversation with the consulting physician. When she relinquished care to the on-coming ED provider Patient #3's disposition was pending since she had not spoken to the cardiologist. The cardiologist needed to determine if Patient #3 required transfer to Hospital B. Patient #3 did not present to the ED with abdominal pain and had no abdominal pain while she cared for him. When questioned for her professional opinion if a continued work up for the abdominal pain could have been considered, she replied she did not want to give an opinion because she was not there.

During a telephone interview on 09/09/25 at 1:45 PM, Staff L, Physician, stated that she did not recall Patient #3 and she did not have access to his medical record. She believed he was being transferred because of his cardiology needs to his cardiologist at Hospital B. The transfer process was in progress prior to her assumption of his care. She did not recall speaking to Patient #3's cardiologist or that the patient had requested a transfer to Hospital B. The CT scan results did not indicate an emergency. His gallbladder could have been evaluated as an outpatient. If the situation was emergent, he could have been evaluated by a surgeon at Hospital A.

During an interview on 09/09/25 at 2:03 PM, Staff P, Risk Manager, stated that the cardiac catheterization laboratory was available from 6:30 AM to 3:00 PM.