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.

ST LOUIS UNIVERSITY HOSPITAL 3635 VISTA AVE SAINT LOUIS, MO 63110 July 14, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on staff interviews, policy and medical record review, the hospital failed to enforce its policies and procedures and did not provide a medical screening exam (Visitor #25 and Patient #2) with an emergency medical condition out of 25 medical records selected for review from January to July 8, 2011. The facility Emergency Department (ED) sees an average of 3200 patients per month.

Findings included:

1. Review of the facility's "EMTALA" Policy & Procedure effective 12/04/03 and revised 06/10 showed the following direction:
-that a patient who presented on Hospital property and requests examination or treatment for what may be an emergency medical condition, or has such request made on his or her behalf is deemed to have "come to the emergency department." ...it is the policy of the hospital if an individual comes to the Emergency Department that the hospital will provide a Medical Screening Examination (MSE) within the capability of their "dedicated emergency department." The hospital failed to follow this policy and failed to provide Visitor #25 and Patient #2 with a MSE.

2. Review of the Hospital TRANSFER REVIEW & EVALUATION FORM dated 06/28/11 stated that a one year old child (Visitor # 25) came to see his Mother (patient) on May 23, 2011 at approximately 3:35 PM. Visitor # 25 fell in the Mother's room and was bleeding from his forehead. Visitor #25's Mother went to the nursing station and said that her son was bleeding and she needed help. The nurses placed ice on Visitor #25's head and transported him to Hospital B's ED. The form lacked evidence that a Medical Screening Exam (MSE) and stabilizing treatment had not been completed by the Hospital and the family had not requested a transfer to Hospital B. No contact was made by the Hospital staff to the Hospital ED and staff did not contact Hospital B prior to the transfer. Staff did not enter visitor # 25's name in the ED log (tracks the care provided to each individual who comes to the hospital) as the child was not escorted to the Hospital ED.

Review of the medical record from Hospital B (second hospital) revealed Visitor #25 arrived at it's ED at 4:03 PM on 5/23/11 and received an examination and treatment for his injury.

During an interview on 07/12/11 at 2:15 PM,, Staff 3, Director of the Hospital (St Louis University) ED, stated that he/she would expect any visitor/family who was on hospital grounds and injured to be brought to our ED.

During an interview on 7/12/11 at 2:22 PM Staff 5, Registered Nurse, on 6 South at the Hospital stated that her patient came to the nursing station saying her son had fallen and hurt his head and needed help. Staff 5 and Staff 14, RN , started to the room when the Father came into the hall carrying the child (visitor # 25). They applied ice to his head and placed the child and his Father in a wheelchair and took them to the ED at Hospital B.

During a phone interview on 7/19/11 at 4:58 PM Staff 13, Unit Manager of 6 South, stated that Staff 14 requested her approval to take visitor # 25 and his father to the ED at Hospital B for care because the Hospital does not have a pediatrics unit.

During an interview on 7/13/11 at 9:00 AM Staff 2, the Hospital's Compliance Officer, stated that he/she came to the conclusion that we should have recognized it (injury) as a need to go to our ED for a medical screening examination.

3. Review of Patient #2's medical record states the patient presented to the ED with his/her parent on 05/17/2011 at 5:24 PM. The nurse documented the Mother presented to the ED seeking care because her child had a fever, cough and rapid respirations. The nurse documented she explained to the mother that "we would be happy to see child and medically screen pt [patient] but since we do not see pediatric pts should she need further treatment or admission pt would be transferred to [Hospital B]." "Pt did not appear in any distress and mother decided to take child directly to [Hospital B]."

Review of Patient #2's medical record showed that Patient #2 arrived at Hospital B's ED on 05/17/2011 at 5:41 PM and received an examination and treatment that the Hospital (St Louis University) was capable of providing.

During an interview on 07/14/11 at 11:52 AM Staff 9, Emergency Department Registered Nurse, stated that she did not recall Patient #2 but stated that the documentation dated 05/17/2011 which was shown to her was her documentation and did accurately reflect what she may say to any parent who presents to the ED with a child.

4. During an interview on 07/13/11 at 2:40 PM Staff 8 the Risk Manager stated that she reviewed the Occurrence Report on May 26, 2011 and confirmed that Visitor # 25 was injured inside the hospital but staff did not take the visitor to the ED for an exam as required. The Risk Manager confirmed that once she identified this as a violation of EMTALA, the hospital took the following corrective action:

1) The HCO (Hospital Compliance Officer) reviewed the EMTALA requirements with the involved nurses on June 28, 2011. 2) The HCO identified an article for Pulse (the hospital newsletter) titled "EMTALA; How to Manage Clinical Emergencies Involving a Pediatric Visitor on July 21, 2011. 8) The hospital placed signage on the tunnel door which connects it to the second hospital reminding staff of EMTALA transfer obligations - Permanent sign to be placed on August 15, 2011. 4) The hospital revised two policies completed on July 11, 2011 A) Pediatric Patient Emergencies and Treatment policy was revised to ensure staff understand the care of the pediatric patient in the Emergency Department to anyone under the age of 16 presenting anywhere on the hospital campus seeking care for an emergency medical condition will be medically screened and treated as appropriate in the Emergency Department. Patients requiring care beyond the capability of the hospital will be appropriately transferred ...B) Visitor and Guest Event Management policy was initiated to provide clear guidance on EMTALA compliance if a clinical emergency were to arise. 5) All Nurse Managers were added to the "Required Training Roster" for EMTALA and completed initial training on July 22, 2011.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview and record review, the hospital failed to provide two individuals (Visitor #25 and Patient #2) with an examination out of 25 cases sampled from January - July 8, 2011. The facility Emergency Department (ED) sees an average of 3200 patient a month.

Findings included:

1. Record review of the facility's "EMTALA" Policy/Procedures effective 12/04/03 and revised 06/10 showed the following direction:
-that a patient who presented on Hospital property and requests examination or treatment for what may be an emergency medical condition, or has such request made on his or her behalf is deemed to have "come to the emergency department." ...it is the policy of the hospital if an individual comes to the Emergency Department that the hospital will provide a Medical Screening Examination (MSE) within the capability of their "dedicated emergency department." The hospital failed to follow this policy and failed to provide Visitor #25 and Patient #2 with a MSE.

2. Review of the Hospital TRANSFER REVIEW & EVALUATION FORM dated 06/28/11 stated that the one year old child was visiting his Mother on May 23, 2011 at approximately 3:35 PM. Visitor # 25 fell in the Mothers room and was bleeding from his forehead. Visitor #25's Mother went to the nursing station and said that her child was bleeding and she needed help. The nurse's placed ice on Visitor #25's head and transported him/her to a second hospital's ED. The form did not include evidence that a Medical Screening Exam (MSE) and stabilizing treatment had been completed by the hospital and the family had not requested a transfer to a second hospital. No contact was made by hospital staff to the hospital ED. The second hospital was not contacted prior to the transfer. The patient was not placed in the log as the child was not escorted to the hospital ED.

During an interview on 07/12/11 at 2:15 PM,, Staff 3, Director of ED, stated that he/she would expect any visitor/family who was on hospital grounds and injured to be brought to the hospitals ED.

Record review of the medical record from the second hospital stated the Visitor #25 arrived at the second hospital's ED at 4:03 PM and was treated with Dermabond (glue) for a one cm laceration of the left forehead.

3. Record review of Patient #2's ED medical chart states the patient came with his/her parent on 05/17/2011 at 5:24 PM.

The nursing documentation showed that the Mother said the child had a fever, cough and rapid respirations. The nurses notes further documented that the ED would be happy to see the child and medically screen the patient but since we do not see pediatric patients and should he/she need further treatment or admission, the patient would be transferred to another hospital. The Mother signed the Refusal of Medical Screening Exam for Pediatric Patient by an Emergency Department Physician and left the hospital.

Review of Patient #2's medical record showed that Patient #2 arrived at Hospital B's ED on 05/17/2011 at 5:41 PM and received an examination and treatment that the hospital (St Louis University) was capable of providing.

During an interview on 07/14/11 at 11:52 AM Staff 9, Emergency Department Registered Nurse, stated that she did not recall Patient #2 but stated that the documentation dated 05/17/2011 which was shown to her was her documentation and did accurately reflect what she may say to any parent who presents to the ED with a child.

During an interview on 07/12/11 at 2:15 PM,, Staff 3, Director of ED, stated that he/she would expect any visitor/family who was on hospital grounds and injured to be brought to the hospitals ED.

During an interview on 07/12/11 at 2:22 PM Staff 5, Registered Nurse, on 6 South stated that her patient came to the nursing station saying her child had fallen and hurt his head and needed help. Staff 5 and Staff 14, RN , applied ice and the child and his Father were placed in a wheelchair and taken to a second hospital's ED.

During an interview on 07/13/11 at 9:00 AM Staff 2, Compliance Officer, stated that he/she had come to the conclusion that we should have recognized it (injury) as a need to go to our ED for screening and was an EMTALA.

During a phone interview on July 19, 2011 at 4:58 PM Staff 13, Unit Manager of 6 South, stated that she was not present at the time of the incident. She stated that the nurse who was mentoring Staff 5 made the decision to take the child to the ED of the second hospital because they did not have a pediatrics unit and when she was asked by Staff 14, she said ok.

During an interview on 07/13/11 at 2:40 PM the Staff 8 the Risk Manager stated that she reviewed the Occurrence Report on May 26, 2011 and confirmed that Visitor # 25 was injured inside the hospital but staff did not take the visitor to the ED for an exam as required. The Risk Manager confirmed that once she identified this as a violation of EMTALA, the hospital took the following corrective action:

1) The HCO (Hospital Compliance Officer) reviewed the EMTALA requirements with the involved nurses on June 28, 2011. 2) The HCO identified an article for Pulse (the hospital newsletter) titled "EMTALA; How to Manage Clinical Emergencies Involving a Pediatric Visitor on July 21, 2011. 8) The hospital placed signage on the tunnel door which connects it to the second hospital reminding staff of EMTALA transfer obligations - Permanent sign to be placed on August 15, 2011. 4) The hospital revised two policies completed on July 11, 2011 A) Pediatric Patient Emergencies and Treatment policy was revised to ensure staff understand the care of the pediatric patient in the Emergency Department to anyone under the age of 16 presenting anywhere on the hospital campus seeking care for an emergency medical condition will be medically screened and treated as appropriate in the Emergency Department. Patients requiring care beyond the capability of the hospital will be appropriately transferred ...B) Visitor and Guest Event Management policy was initiated to provide clear guidance on EMTALA compliance if a clinical emergency were to arise. 5) All Nurse Managers were added to the "Required Training Roster" for EMTALA and completed initial training on July 22, 2011.