The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

FREEMAN NEOSHO HOSPITAL 113 WEST HICKORY STREET NEOSHO, MO 64850 May 20, 2011
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to provide an adequate medical screening examination, within their capability, to determine whether an emergency medical condition existed for three patients (Patients # 21, 34, and 37) of 40 sampled patients who presented to the Emergency Department (ED) requesting treatment from November 2010 to May 2011.

Findings included:

1. Review of the facility ED log showed Patient #21 (MDS) dated [DATE]. Review of Patient #21's medical record showed that:
?Patient was triaged at 14:01 with chief complaint of right arm numbness and tingling;
?Initial vital signs included blood pressure of 160/96, skin flushed, and medications of Coumadin (blood thinner), Digoxin ( heart medication), Metformin (for diabetes);
?Patient #21's Registration/Admission form indicates: Stroke Activity, HX (history);
?Patient taken to room 101A via wheel chair at 14:04;
?RN established intra venous (IV) access at 14:10;
?At 14:30 Staff A (RN) documented Staff B (ED physician) in to see patient;
?Staff B documented Patient #21 chief complaint right arm tingling a few minutes prior to arrival. Staff B documented that Patient # 21 had a history of diabetes, dysrhythmia (heart beat irregularity), and previous stroke. Patient # 21 was hypertensive (high blood pressure) upon arrival to the emergency department. All of these conditions increase patients' risk for stroke (http://www.stroke.org/site/PageServer?pagename=risk);
?Additional documentation by Staff B revealed Patient #21 should arrange a carotid ultrasound (imaging study to evaluate blood flow through the neck blood vessels) through his/her primary care provider ASAP (as soon as possible);
?Medical record did not contain evidence that ED physician B ordered any blood tests, an EKG (heart tracing), a CT (Computerized Tomography) scan of the brain (to determine if blood clot or bleeding was present) or that Staff B performed a neurological examination in order to determine if Patient # 21 was experiencing an emergency medical condition.

During an interview on 05/19/11 at 2:15 PM Staff D, Radiology Manager, stated that the CT scanner was never out of service and was fully staffed on 5/6/11.

During an interview on 05/20/11 at 8:05 AM Staff B, ER physician, stated that if a patient presented with neurologic symptoms that included weakness, he/she would typically order a work up that consisted of lab tests, CT scan, EKG and a physical examination.

During an interview on 5/20/11 at 09:15 AM Staff C, ED Director, stated that if a patient presented with neurologic symptoms including numbness, tingling on one side with co-morbidities that include diabetes, previous stroke history and blood thinning medication he/she would expect a work up that included labs, CT scan, EKG. He/she stated that the ED Neuro Protocol (Physician order set) could be initiated. Protocol indicated:
-Cardiac and O2 monitor;
-EKG (heart tracing), CBC, CMP, U/A (lab tests), PCXR (portable chest x-ray), PT with INR (lab test) if on Coumadin (blood thinner);
-CT scan of brain without contrast for stroke/syncope in elderly or CAD (coronary artery disease) risk factors.
Staff C stated that the ER was fully staffed on 5/6/11 during the day shift.

During an interview on 05/20/11 at 11:05 AM Staff A, RN, stated that he/she would expect that a patient arriving with neurologic symptoms including numbness, tingling or weakness be taken directly to a treatment room and evaluation would include a CT scan, lab tests, EKG, IV access and remain NPO (nothing by mouth).

According to the statutorily mandated Quality Improvement Organization physician peer review performed on June 29, 2011, Patient # 21 did not receive an appropriate medical screening examination sufficient to determine whether she had an emergency medical condition prior to discharge.

2. Record review showed that patient #21 was admitted to another hospital (Hospital B) on 05/10/11 for examination and treatment of a stroke.

3. Review of 2 of 39 additional Emergency Department medical records showed:

Patient #34, a [AGE] year old male presented to ED on 03/17/11 at 3:36 AM complaining that he could not urinate. Documentation revealed the patient had history of a herniated disc and an enlarged prostate. Further documentation revealed ED physician B ordered placement of an indwelling urinary catheter and a urine analysis. At 4:15 AM the ED nurse documented 1,000 cc (1 liter) of urine was drained from Patient # 34's bladder. At 4:40 AM ED Physician B discharged Patient # 34 from the ED with instructions to follow up with a urologist at another hospital. The medical record did not contain evidence ED Physician B performed a neurological exam or testing to determine whether patient # 34's acute urinary retention (inability of the bladder to empty) was due to an enlarged prostate or a serious medical complication resulting from a herniated disc (compression of the spinal cord resulting in temporary or permanent bladder dysfunction). According to the statutorily mandated Quality Improvement Organization physician peer review performed on June 29, 2011 the hospital did not provide Patient # 34 with an appropriate examination sufficient to determine whether an emergency medical condition existed prior to discharge.

Patient #37, 76 year old, presented to ED at 7:01 PM on 12/09/10 complaining of pain when urinating. ED Physician B ordered a urine specimen for a urine analysis. The ED nurse documented that Patient # 37 was unable to urinate and declined catheterization as a means for obtaining a urine specimen. ED Physician B cancelled the order for a urinalysis and discharged Patient # 37 with a prescription for an antibiotic and a medication to relieve urinary tract pain, and instructions to follow up with her primary care physician in 2 - 3 days. Patient # 37 left the ED at 7:56 PM. The medical record did not contain evidence that staff monitored Patient # 37's temperature or that any tests were performed to determine the presence of an infection. According to the statutorily mandated Quality Improvement Organization physician peer review performed on June 29, 2011, the hospital did not provide Patient # 37 with an appropriate examination sufficient to determine whether an emergency medical condition existed prior to discharge.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, the facility failed to follow their "EMTALA" policy and did not provide an adequate Medical Screening Examination, within their capabilities, to three (Patient's #21, #34 and #37) of 40 sampled patients who presented to the Emergency Department (ED) requesting treatment from November 2010 to May 2011.

Findings included:

1. Record review of the facility Administrative Policy titled, "EMTALA", last revised in 09/2009, states in part:
Policy: In compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) all individuals that come to a dedicated emergency department of the hospital or elsewhere on hospital property requesting treatment or examination for any medical conditions, will receive an appropriate medical screening examination, regardless if the presenting individual(s) request for examination may clearly indicate that they do not have an emergency. The medical screening will be conducted by the hospital's qualified medical personnel and if an emergency medical condition exists the individual will receive necessary stabilizing treatment or an appropriate transfer.

Medical Screening Exam: Freeman Health System shall provide appropriate medical screening examination within the capability of the hospital ' s emergency department, including ancillary services, routinely available to the emergency department to any individual requesting treatment. The medical screening examination must be similar for patients presenting with symptoms. In providing a medical screening examination, Freeman Health System shall not discriminate against any individual because of diagnosis, financial status, payor source, race, color, national origin, or handicap.

The purpose of the medical screening examination is to determine if an individual is experiencing an emergency medical condition.

Emergency Medical Condition: An emergency medical condition is defined as follows (see 42U.S.C.A.139Sdd): A medical condition manifesting itself by acute symptoms of sufficient severity (including pain), psychiatric disturbances and/or symptoms of substance abuse, 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 of bodily functions;
-Serious dysfunction of any bodily part.

2. The hospital failed to follow its EMTALA policy and did not provide Patient #21 a medical screening examination sufficient to determine if the patient was experiencing a stroke (an emergency medical condition) before discharge. Review of the medical record revealed Patient # 21 (MDS) dated [DATE] at 2:01 PM complaining of tingling in the right arm (a common stroke symptom). Documentation revealed Patient # 21 was hypertensive (high blood pressure), took a medication to thin her blood, had a prior history of stroke, cardiac arrhythmia (unusual heart beat) and diabetes (control of blood sugar) - all of these conditions increase an individual's risk for stroke (http://www.stroke.org/site/PageServer?pagename=risk). The medical record lacked evidence that ED physician B ordered blood tests, an EKG (tracing of electrical activity in the heart), CT scan (Computerized Tomography) imaging study of the brain or performed a neurological exam to determine that Patient # 21 did not have an emergency medical condition. Refer to Tag A2406 for details.

3. The hospital failed to follow its EMTALA policy and did not provide Patient # 34 a medical screening examination sufficient to determine if the patient was experiencing an emergency medical condition prior to discharge. Review of the medical record revealed Patient #34 presented to ED on 03/17/11 at 3:36 AM complaining of an inability to urinate. Documentation revealed Patient # 34 had history of a herniated disc (spinal disc disease) and an enlarged prostate. The medical record lacked evidence that Physician B performed an examination sufficient to determine if Patient # 34's acute urinary retention was due to an enlarged prostate or a serious neurologic complication of a herniated disc. Refer to Tag A2406 for details.

4. The hospital failed to follow its EMTALA policy and did not provide Patient # 37 a medical screening examination sufficient to determine if the patient was experiencing an emergency medical condition prior to discharge. Review of the medical record revealed Patient # 37 presented to ED on 12/09/10 at 7:07 PM complaining of painful urination. Documentation revealed the ED staff did not obtain or monitor Patient # 37's temperature. ED Physician B did not perform a sufficient examination, or obtain test results to determine the source for Patient # 37's painful urination. Refer to Tag A2406 for details.