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.

SOUTHEASTHEALTH CENTER OF STODDARD COUNTY 1200 N ONE MILE RD DEXTER, MO 63841 March 11, 2015
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and policy review, the facility failed to provide a Medical Screening Examination (MSE) within the facility's capacity and capability to determine if an Emergency Medical Condition (EMC) existed for one patient (#1) out of 22 Emergency Department (ED) patient records reviewed. This had the potential to affect all patients who presented to the ED. The ED average daily census was 35, the average monthly census was 1,036, and the total transfers from 10/01/15 through 03/09/15 was 274. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) Regulations - Transfer Regulations," approved 09/2014, showed a MSE refers to the process to determine if an Emergency Medical Condition (EMC) exists. If an individual comes to the Emergency Department (ED) and a request is made on the individual's behalf for examination or treatment of a medical condition, the facility will provide for an examination or treatment within the capability of the ED, the screening examination will be ongoing, and there will be evidence of evaluation immediately prior to discharge or transfer.

2. During an interview on 03/10/15 at 1:00 PM, Staff D, Physician Assistant (PA), stated that on 01/15/15:
-Patient #1 came in to the rural health clinic (RHC-a physicians' office building that was affixed to the hospital building where the ED was located) where Staff D worked for a two month well baby check and she noticed jaundice (a disease that causes the skin to turn yellow) with poor weight gain.
- She completed blood work and noted elevated liver enzymes (may indicate a problem with liver functioning).
- His mother had not noticed anything acute (very serious or dangerous: requiring serious attention or action).
- She contacted a hospital in Cape Girardeau and they recommended transfer to a children's hospital in St. Louis.
- She contacted a children's hospital in St. Louis, at 4:36 PM, and spoke with a physician about the need for the patient to be seen by a specialist.
- At approximately 5:00 PM, the receiving facility made arrangements for air transport of the patient.
- Since the RHC was closing, she contacted Staff B, the Assistant Administrator, about finding a comfortable place in the hospital where Patient #1 and his mother could wait until transport arrived.
- Staff B told Staff D to take Patient #1 to the ED.
- She walked with the mother, who was carrying the patient, from the RHC clinic to the ED. Even though the PA brought Patient #1 to the ED, the patient was not provided an MSE to determine if an EMC existed.
- The ED was busy, so she called Staff B back and was told told to have Patient #1 and the mother wait in a vacant room on the Intensive Care Unit (ICU).
- She walked with the mother, who was carrying Patient #1, to the ICU.
- She told an ICU nurse, Staff L, that Patient #1 was being transported to a children's facility in St. Louis and the baby and mother needed a comfortable place to wait. They were placed in a vacant ICU room.
- She was with the patient and mother until approximately 6:30 PM when she (Staff D, PA) left the hospital.
- She left no orders and did not expect nursing staff to do anything for Patient #1.
- She did not document the times and/or the course of events after leaving the clinic and while the patient was in the hospital setting.

3. Record review of Patient #1's RHC record documentation, which included a form titled, "Healthy Children and Youth Screening Guide, Two to Three Months," dated 01/15/15, showed the following:
- There were no times documented on the form or anywhere in the record about the course of events.
- Patient #1 was spitting up frequently, had an episode of projectile vomiting (vomiting that is sudden and so vigorous that it is forcefully projected to a distance), and had yellowing of the skin over the last week.
- During the physical examination the patient cried and did not appear well.
- He had a dusky (somewhat darkened) yellow skin color.
- Staff D, PA, diagnosed the patient with failure to thrive (a condition that may be caused by medical problems or factors in the child's environment), jaundice, and elevated liver enzymes.
- Staff D made arrangements for Patient #1 to be picked up by an air team that evening and be directly admitted to a St. Louis children's hospital.
- Patient #1's RHC record showed no other documentation by the PA on 01/15/15 after leaving the clinic, going to the hospital to wait for transport, and up until the time the transfer occurred that evening, at approximately 7:45 PM.

Even though requested, the facility could not provide documentation Patient #1 ever presented to the ED, was in observation, or in the ICU.

4. During an interview on 03/10/15 at 1:35 PM, Staff B, stated that she remembered receiving a call from Staff D on 01/15/15 at approximately 6:00 PM, that the RHC was closing and Staff D needed a comfortable place where Patient #1 and his mother could wait until transport arrived. She directed Staff D to try the ED. Staff B got another call from Staff D, a little later, stating that the ED was too busy. Staff B suggested that they speak with the facility's Risk Manager (RM, Staff Z). Staff B contacted Staff Z and was told there was a vacant ICU room. Staff B left the rest of the arrangements for Patient #1 up to Staff Z.

5. During an interview on 03/10/15 at 4:45 PM, Staff I, Physician, stated he worked in the ED on 01/15/15 and he was not aware of Patient #1 presenting to the ED or in the facility.

6. Record review of the ED log, dated 01/15/15 showed no evidence of Patient #1's arrival to the ED. The ED had five beds and they treated 24 patients on 01/15/15. There were approximately two patients registered in the ED at approximately 6:00 PM, or when Patient #1 presented to the ED.

7. During an interview on 03/10/15 at 4:20 PM, Staff L, RN, stated that Staff D arrived on the ICU unit with Patient #1 and his mother. Staff D asked Staff L if they (Patient #1 and mother) could wait in their area until transport arrived, she agreed, and they went to an empty ICU room to wait. The PA handed her the clinic paperwork. Staff L noted high lab values and that the patient needed a higher level of care. She assumed it was okay for Patient #1 to be left in the ICU without physician orders since her supervisors, the Chief Nursing Officer (CNO) and RM were both present and they had not objected. Staff L confirmed there were no orders for treatment and no record of the Patient #1 having been there. She left work about 7:15 PM and Patient #1 was still waiting for transport.

8. During an interview on 03/10/15 at 4:12 PM, Staff K, RN, stated that she remembered the baby, mother, and father waiting on the ICU for transport to a hospital. She checked in to see if the mother needed anything, she provided no assessment, vital signs or other treatment for the baby.

9. During an interview on 03/11/15 at 4:10 PM, Staff G, Pediatrician, stated that he was Staff D's supervising physician and Staff D did not consult with him on 01/15/15. He was not aware that Patient #1 and mother waited in an ICU room until transfer. If contacted, he would have told Staff D to stay with the patient, or he would have arranged for ED care until transport.

10. Record review of the Emergency Medical Service (EMS) transport records dated 01/15/15, the Transport Team Pediatric Orders (undated), the Pre-Admission Communication Summary dated 01/15/15, and the admitting History and Physical dated 01/16/15, from the receiving hospital showed the following:
- On 01/15/15 at 4:38 PM, the childrens hospital received a call from Staff D and she was connected to a physician. The PA reported that Patient #1 was brought in for a well baby check and was noted to have poor weight gain, yellow gray skin and appeared very emaciated. The physician asked her to place an IV and get an EKG if possible.
- At 6:42 PM the transport team reported that the air transport would not be able to leave the airport until 7:00 PM due to pilot duty time.
- At 7:45 PM the transport team contacted the receiving hospital and reported that they had just arrived to pick up Patient #1.
- The Transport Team Pediatric orders included vital sign monitoring every 15 minutes and IV fluids.
- The transport team documented the patient was emaciated (abnormally thin or weak, especially because of illness or lack of food) and jaundiced, and it took them four attempts to start an IV and give fluids (may be a sign of dehydration).
- Patient #1 arrived at the childrens hospital in St. Louis at approximately 10:00 PM, or approximately five and one-half hours after the patient was accepted by the receiving hospital.
- The admitting History and Physical showed problems of jaundice, failure to gain weight in infancy, and anemia (the blood is not able to carry enough oxygen to the rest of the body). The physician diagnosed the patient with [DIAGNOSES REDACTED] (a condition in which the flow of bile that helps with digestion is slowed or blocked from the liver).
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on a review of Emergency Medical Services Documents, Emergency Department (ED) Logs, Medical Records, Medical Staff Bylaws, Medical Staff Rules and Regulations and staff interviews, it was determined the facility failed to ensure one patient (#1) of 22 patient who presented to the ED received a medical screening examination. Please refer to A2406.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on interview and record review the facility failed to enter one (#1) patient of 22 patients that presented to the Emergency Department (ED) into the ED log. This had the potential to affect all patients who presented to the ED. The facility census was 14.

Findings included:

1. Record review of the facility's policy titled, "EMTALA [Emergency Medical Treatment and Labor Act] Regulations - Transfer Regulations," revised 09/2014, showed Staff will maintain a central log on each patient that comes to the ED seeking care. The central log will include refusal of treatment, or if the patient was transferred, admitted and treated, stabilized and transferred, or discharged .

2. During an interview on 03/10/15 at 9:16 AM, Staff C, ED registration clerk, stated that it was her responsibility to greet ED patients, obtain their name, address, date of birth and nature of complaint. This information was then supposed to be entered into the ED log.

During an interview on 03/10/15 at 1:00 PM, Staff D, Physician Assistant (PA), stated that on 01/15/15:
-Patient #1 came in to the rural health clinic (RHC, a physicians' office building that was affixed to the hospital building where the ED was located), where Staff D worked, for a two month well baby check and she noticed jaundice (a disease that causes the skin to turn yellow) with poor weight gain.
- Staff D completed blood work on Patient #1 and noted elevated liver enzymes (may indicate a problem with liver functioning).
- Staff D contacted a hospital in Cape Girardeau and they recommended transfer to a children's hospital in St. Louis.
- Staff D contacted a children's hospital in St. Louis, at 4:36 PM, and spoke with a physician about the need for the patient to be seen by a specialist.
- Since the RHC was closing, she contacted Staff B, the Assistant Administrator, about finding a comfortable place in the hospital where Patient #1 and his mother could wait until transport arrived.
- Staff B told Staff D to take Patient #1 to the ED.
- She walked with the mother, who was carrying the patient, from the RHC clinic to the ED. Even though the PA took Patient #1 to the ED, the patient was not entered into the ED log.

Record review of the ED log, dated 01/15/15 showed no evidence of Patient #1's arrival to the ED.

Even though requested, the facility could not provide documentation Patient #1 ever presented to the ED.