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.

BELTON REGIONAL MEDICAL CENTER 17065 S 71 HIGHWAY BELTON, MO 64012 May 13, 2020
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview, record review, policy review, and surveillance video recording review, the hospital failed to provide a Medical Screening Exam (MSE) for one patient (#1), within the hospital's capability/capacity to determine if an Emergency Medical Condition (EMC) existed when the patient was within 250 yards of the hospital's Emergency Department (ED) entrance. A total of 22 ED medical records were reviewed of patients that presented to the hospital's ED seeking care/treatment, out of a sample selected from July 2019 through May 2020. These failures by the hospital had the potential to affect all patients that presented to the hospital's ED seeking medical care/treatment. The hospital's ED saw an average of 2,250 emergency visits per month over the past 10 months.

Findings included:

Review of the hospital's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening Examination and Stabilization Policy," dated 05/01/17, showed the following directives for staff:
- EMTALA obligation is triggered when an individual arrives on the hospital property, either in the Dedicated Emergency Department (DED) or property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson to believe that the individual needed such examination or treatment.
- The hospital must perform an MSE to determine if an EMC exists. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.

Review of the surveillance video recording showed:
- A man walked across the ED parking lot in the direction of the hospital's ED entrance. As he walked towards the ED entrance, he put his right hand over his chest.
- After the man stepped up on the curb, he stumbled forward a couple of steps, with both arms stretched out in front of him, he lowered his body down and sat on the ground while leaning against a transformer box.
- The man then slumped forward, placed his hands on the ground, lowered his body down and rested his face on the ground with his legs bent in a fetal position.
- As Staff J, off-duty ED Physician, walked to his car, he looked in the direction of where the man laid, however, Staff J did not go to where the man laid but continued to walk to his car.
- Staff J opened the driver's door, reached into his left pants pocket, pulled out a phone, placed it up to his right ear, shut the driver's door and faced in the direction where the man laid as he talked on the phone.
- Staff J then opened the driver's door, removed his stethoscope from around his neck and placed the stethoscope into the car and shut the door.
- Staff J then proceeded to walk in the direction to where the man laid.
- When Staff J approached the man, he did not make physical contact with the man down on the ground.
- Staff E, Security Officer, arrived and walked to where the man was, kneeled down next to the body and appeared to touch the man.
- Staff I, Paramedic/ED Technician, arrived and went directly to the body, squatted down next him, appeared to be checking for a pulse and then rolled the man over onto his back.
- Staff J and Staff I appeared to be engaged in a conversation and then Staff I placed a sheet over the man.
- Emergency Medical Services (EMS, ambulance), local police, and fire/rescue arrived to the ED parking lot.

Staff J, off-duty ED Physician, was observed on the surveillance video recording removing his stethoscope before he walked over to the location where the man laid face down on the ground approximately 20 feet from where his car was parked. Review of the surveillance video recording showed that Staff J never made physical contact with the man to see if the man required any type of first aide or if the man presented with an emergency condition.

Based on interviews conducted with:
- Staff A, Chief Executive Officer;
- Staff D, Registered Nurse (RN), Director of Emergency Services;
- Staff E, Security Officer;
- Staff G, RN, ED Charge Nurse;
- Staff H, RN, ED Nurse;
- Staff F, RN, House Supervisor; and
- Staff I, Paramedic/ED Technician
Staff reported that Staff J, off-duty ED Physician, used his authority as a medical physician to prevent hospital staff from providing care, treatment or to transfer the man found down into the ED. Staff reported that Staff J informed them that he was in charge, he was a physician and it was "his call" therefore, staff did not feel that they had the authority to not follow Staff J's orders when he "ordered" staff not to touch the body because it was a crime scene.

During a telephone interview on 18/20 at 4:30 PM, Staff J, off-duty ED Physician stated that:
- When he walked out of the ED side door to where his car was parked, he glanced over in the direction of the transformer box and thought he saw something.
- When he reached his car, he noticed what he saw was a body lying face down next to the transformer.
- He wanted to ensure the environment was safe before he approached the body, so he retrieved his cell phone, called the ED and requested for Security and the response team to respond to a body that was down on the ground next to the transformer box.
- When he saw Staff E, Security Officer, exit the ED entrance, he started to walk to the location of the body.
- When he reached the body, he noticed blood coming from the man's nose and mouth.
- He did not perform a pulse check on the downed man because he did not have gloves on to touch the body and he stood approximately six inches away from the body as he made his initial assessment.
- He shone a light from his phone onto the man and noticed the body had lividity (reddish- to bluish-purple discoloration of the skin due to the settling and pooling of blood following death).
- When the body was rolled over, he observed the body had lividity and trauma to the forehead and nose and at that point he believed it was a "crime scene", however, Staff J did not initiate any type of care/treatment.
- The man was deceased so no cardiopulmonary resuscitation (CPR, a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) was required.
- The delay in treatment for the downed man was due to it being nighttime and concern for his (Staff J) safety, so he requested for security to come to the scene before he approached the body.
- He did not know if the person on the ground experienced a drug overdose, was intoxicated, or a homeless person sleeping and without knowing what the situation presented he thought the person could possibly attack and harm him.
- He was the only "qualified" provider on the scene and it was "his call" not to start CPR based on his assessment of the patient.

During an interview on 05/13/20 at 9:26 AM, Staff C, ED Physician, ED Medical Director, stated:
- He received a telephone call from Staff J, off-duty ED Physician, at approximately 10:40 PM (07/16/19) and Staff J reported to him that he found a man down and the body was dead, very dead and had lividity.
- Staff J reported that he was not moving the body because he believed it was a "crime scene."
- He believed Staff J had performed a MSE on the downed man to rule out if an EMC existed.
- Even if the scene was a "crime scene", he expected Staff J to render medical care/treatment while preserving the environment if it was a "crime scene."
- After Staff J determined the environment was safe, he expected Staff J to proceed with performing a medical assessment since Staff J was a medical physician and was present on the scene, he expected Staff J to render care within the scope of his medical practice.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview, record review, policy review, and surveillance video recording review, the hospital failed to provide a Medical Screening Exam (MSE) for one patient (#1), within the hospital's capability/capacity to determine if an Emergency Medical Condition (EMC) existed when the patient was found face down on the ground within 250 yards of the hospital's Emergency Department (ED) entrance. The hospital's failure to provide the patient with a MSE placed the patient at increased risk for determining if an EMC existed. A total of 22 ED medical records were reviewed of patients selected from the ED Central Log that presented to the hospital's ED seeking care/treatment, out of a sample selected from July 2019 through May 2020. These failures by the hospital had the potential to affect all patients that presented to the hospital's ED seeking medical care/treatment. The hospital's ED saw an average of 2,250 emergency visits per month over the past 10 months.

Findings included:

Review of the hospital's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening Examination and Stabilization Policy," dated 05/01/17 showed the following directives for staff:
- EMTALA obligation is triggered when an individual arrives on the hospital property, either in the Dedicated Emergency Department (DED) or property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment.
- The hospital must perform an MSE to determine if an EMC exists. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital. A physician examines all individuals whose conditions or symptoms require physician examination.

Observation on 05/12/20 at 11:01 AM, of the ED parking lot showed that it was approximately 60 feet from the ED side door that Staff J, off-duty ED Physician, exited to where his car was parked in the ED parking lot and approximately 20 feet from his parked car to the location where the body was observed.

Review of the surveillance video recording showed:
- A man walked across the ED parking lot in the direction of the hospital's ED entrance and as he walked, he put his right hand over his chest.
- After the man stepped up on the curb, he stumbled forward a couple of steps, with his arms stretched out in front of him, he lowered his body down and sat on the ground while leaning against the transformer box.
- The man then slumped forward, placed his hands on the ground, lowered his body down and rested his face on the ground with his legs bent in a fetal position.
- Approximately seven and a half minutes later, Staff J, off-duty ED Physician, appeared in view of the surveillance video recording and walked to his car.
- As Staff J walked to his car, he looked in the direction of where the man laid, however, Staff J did not go to the man but continued to walk to his car.
- When Staff J reached his car, he opened the driver's door, turned and looked in the direction of where the man was, reached into his left pants pocket, pulled out a phone and for approximately one minute and three seconds looked down at the phone, then placed the phone up to his ear, turned and faced the direction of the man on the ground as he appeared to talk on the phone.
- After approximately 36 seconds, Staff J opened the driver's door, removed his stethoscope from around his neck and placed the stethoscope into the car and shut the door.
- Staff J then proceeded to walk to where the man was located.
- When Staff J reached the man, he did not make any physical contact/touch the man, for example, he did not assess to see if the man had a pulse, heartbeat, or was breathing.
- Staff E, Security Officer (SO), arrived, walked to where the man laid, appears to be talking to Staff J, then kneeled down and appeared to touch the man.
- Staff I, Paramedic/ED Technician, arrived, went directly to the man, squatted down next to him, rolled him over onto his back and appeared to touch the man's neck area.
- Emergency Medical Services (EMS, ambulance), local police, and fire/rescue arrived to the ED parking lot.

Review of the EMS Pre-Hospital Care Report dated 07/17/19 showed that:
- At 11:47 PM, EMS was dispatched for a man found down on hospital property and was enroute to the scene at 11:49 PM.
- At 11:51 PM, EMS arrived on the scene and there was no CPR or life-saving procedures being performed on the patient when EMS arrived.
- EMS received report that the patient was found lying supine (lying horizontally with face and torso facing up), he was not breathing and did not have a pulse.
- At 11:54 PM, EMS placed a four lead cardiac monitor (device that detects heart activity) on the patient and the monitor showed the patient did not have any cardiac activity.
- The patient was covered in a sheet and left in the custody of local police.

During a telephone interview on 18/20 at 4:30 PM, Staff J, off-duty ED Physician stated that:
- When he walked out of the ED side door to where his car was parked, he glanced over in the direction of the transformer box and thought he saw something.
- When he reached his car, he noticed what he saw was a body lying face down next to the transformer.
- He wanted to ensure the environment was safe before he approached the body, so he retrieved his cell phone, called the ED and requested for Security and the response team to respond to a body that was down on the ground next to the transformer box.
- When he saw Staff E, Security Officer, exit the ED entrance, he started to walk to the location of the body.
- When he reached the body, he noticed blood coming from the man's nose and mouth.
- He did not perform a pulse check on the downed man because he did not have gloves on to touch the body and he stood approximately six inches away from the body as he made his initial assessment.
- He shone a light from his phone onto the man and noticed the body had lividity (reddish- to bluish-purple discoloration of the skin due to the settling and pooling of blood following death).
- When the body was rolled over, he observed the body had lividity and trauma to the forehead and nose and at that point he believed it was a "crime scene", so he did not initiate any type of care/treatment because he believed the man was deceased so no CPR was indicated/required.
- He was the only "qualified" provider on the scene and it was "his call" not to start CPR based on his assessment of the patient.

The surveillance video recording of approximately 45 minutes showed Staff J, off-duty ED Physician, failed to:
- Make timely contact with the man down on the ground per hospital policies when he delayed approaching the man for approximately two minutes and 15 seconds after he first observed him.
- Perform an adequate assessment when he failed to physically touch the patient and asses for a pulse, respirations, heartbeat, or other trauma that could have caused the man to be down on the ground.

During an interview on 05/11/20 at 3:00 PM and on 05/12/20 at 11:05 AM, Staff A, Chief Executive Officer, (CEO), stated and acknowledged that based on the hospital's surveillance video recording, Staff J, off-duty ED Physician, did not provide care/treatment for the man found face down on the ground by the transformer box and delayed in providing medical care/treatment for the man when he used his authority to prevent other staff from helping the man or allowing staff to bring the man into the hospital's ED.

During a telephone interview on 05/12/20 at 1:04 PM and during an interview on 05/13/20 at 9:26 AM, Staff C, ED Physician, ED Medical Director, stated:
- His expectation was that any person that presents to the hospital's ED or on hospital premises would receive a "hands on" assessment.
- Staff J, off-duty ED Physician, was trained to provide care, so he was not sure why Staff J did not provide the patient with an assessment when Staff J found the patient down on hospital grounds.
- He received a telephone call from Staff J at approximately 10:40 PM (07/16/20) and Staff J reported to him that he found a patient down and the body was dead, very dead and had lividity.
- Staff J reported that he was not moving the body because he believed it was a "crime scene."
- He believed that Staff J had performed an assessment on the patient since Staff J was the first to discover the patient down on the ground.
- Even if the scene was a "crime scene", he expected Staff J to render medical care/treatment while preserving the environment even if it was a "crime scene."
- After Staff J determined the environment was safe, he expected Staff J to proceed with performing a medical assessment since Staff J was a medical physician and was present on the scene, he expected Staff J to render care within the scope of his medical practice.

During an interview on 05/12/20 at 2:26 PM, Staff E, Security Officer (SO), stated:
- A call came over his radio that a person was down in the ED parking lot.
- When he arrived to the ED parking lot, he observed a person face down on the ground and Staff J, off-duty ED Physician, was standing by his car, as he walked to the where the body was, Staff J also walked in the direction of the body.
- He asked Staff J for a report and Staff J informed him that the body had not moved.
- When he asked Staff J if he had approached the downed man prior to his arrival, Staff J replied no and Staff J did not provide him with an explanation as to why he (Staff J) had not approached the man prior to his arrival.
- Together they approached the body, when they arrived next to the body, Staff J spoke to the man but there was no response or movement from him and Staff J never physically touched the man.
- He went to the body, checked for a pulse in the man's neck, however, he did not feel/detect one, so he then checked for a pulse on the man's right wrist but he did not feel/detect one and reported his findings of no pulse to Staff J.
- When an ED staff member rolled the person over from his stomach onto his back, the man did not respond and he visualized that the man's glasses and dentures were crooked and not in place and that the man had an abrasion across his nose without active bleeding.
- He did not recall there being any indication that the man was involved in a crime or that it was a "crime scene" or why Staff J believed that it was a "crime scene."
- When ED staff suggested that the man needed CPR initiated and that the body needed to be moved inside to provide further care/treatment, Staff J stated "NO" and reported that the man had been deceased for approximately one hour, however, his (Staff E) observation did not correspond with the man being deceased for approximately an hour because he had patrolled the ED parking lot approximately 30 minutes prior to finding the man down on hospital property.

During a telephone interview on 05/12/20 at 2:58 PM, Staff G, RN, Charge ED Nurse stated that:
- She received a call requesting for a gurney to be brought outside because someone outside needed one.
- When she arrived outside to where staff and the body was located, staff were discussing if they need to move the body inside to the ED.
- Staff questioned if the patient was still alive and if life support needed to be initiated.
- When Staff I, Paramedic/ED Technician rolled the patient over onto his back, Staff J, off-duty ED Physician, kept repeating to staff not to touch the body due to it being a "crime scene.
- Staff C, ED Physician, ED Medical Director, was called and stated that based on the report he received from Staff J, the person was deceased and not to start CPR.

During an interview on 05/12/20 at 3:19 PM, Staff H, RN, ED Staff Nurse, stated that:
- She answered the phone when Staff J, off-duty ED Physician, called to report that a man was found down in the ED parking lot.
- Staff J requested for a Security Officer to come to the scene before he approached the body and for a gurney to be brought out where the body was found.
- She notified security, then she and Staff I, Paramedic/ED Technician, retrieved a gurney and went to the ED parking lot and observed the patient face down in the grass.
- Staff I went to the body, turned the patient over on his back and Staff J, told Staff I not to move the body due to it being a "crime scene" and because the patient was "dead."
- Staff I then checked the patient for a pulse and reported that he did not have one.
- Staff J was standing away from the body and did not direct staff to initiate CPR on the patient.
- The entire event/incident was confusing to her because Staff J kept repeating that it was a "crime scene", the man was "dead dead" and that Staff J could "pronounce the man deceased " because he was the physician at the scene.
- Staff I informed Staff J that to pronounce a person deceased there needed to be confirmation per electrocardiogram (EKG, a recording of the electrical activity of the heart) leads.
- She heard a staff member request for the local police to be notified.
- Staff J, had poor communication with nursing staff, he was very authoritative and difficult to work with.

During an interview on 05/12/20 at 3:37 PM, Staff F, RN, House Supervisor, stated that:
- She received a call from Staff E, SO, who reported to her that there was a dead body located in the ED parking lot.
- After she received the report from Staff E, she went to the area reported, when she arrived there was pandemonium, so she went to Staff J, off-duty ED Physician, and asked him don't you need to bring this man into the ED, and Staff J replied "he's dead."
- When EMS and the local police arrived she questioned if it was a "crime scene" and staff informed her that Staff J instructed them not to touch the body because it was a "crime scene."
- When the local police arrived on the scene they took over.

During an interview on 05/12/20 at 4:16 PM, Staff I, Paramedic/ED Technician, stated that:
- Staff G, RN, ED Charge Nurse, requested for her to go the ED parking lot and check out the report of a body being found down on the ground.
- As she walked out the ED entrance, she observed Staff J, off-duty ED Physician, and Staff E, SO, standing over a body that was down on the ground.
- When she arrived at the location of the body, she asked Staff J what do we have and Staff J replied he did not know but was emphatic for her not to touch the body because he stated it was a "crime scene", however, she rolled the body over onto his back.
- When the body was rolled over, she noticed that the man's dentures were coming out of his mouth, the patient was extremely cyanotic (bluish/purple discoloration due to lack of oxygen in the blood), so she checked for a carotid pulse (carries blood to the head and neck) but it was absent, the man was not breathing so she checked his chin for rigor (stiffness that occurs after death), however, it was pliable (supple enough to bend freely).
- She instructed Staff G, RN, ED Charge Nurse, that the body needed to be placed on the gurney and transported to the ED, however, Staff J informed staff that they were not moving the body because it was no different than finding someone at a "fast food establishment", it was a "crime scene" and for staff not to touch the body.
- As a paramedic, she had worked several "crime scenes" and still provided care/treatment required after the environment had been declared safe.
- She experienced a lot of conflict because she was trained to provide emergency care/treatment while following physician's orders and when Staff J ordered her not to touch the body or to provide emergent care/treatment, it went against everything she knew needed to be done based on her education/training in providing emergency care/treatment when indicated.

During an interview on 05/13/20 at 8:45 AM, Staff D, RN, Director of Emergency Services stated that:
- She received a call from Staff G, RN, ED Charge Nurse, who reported that there was a dead body outside.
- She asked Staff G if staff had taken a gurney outside, loaded the body on it, transported the body into the ED and Staff G informed her that the body had not been loaded onto the gurney because Staff J, off-duty ED Physician, refused to allow staff to touch the body because Staff J reported it was a "crime scene."
- She instructed Staff G to load the body onto the gurney, however, Staff J took the phone and informed her that it was "his call", it was a "crime scene" and that the local police and coroner were notified because the body was "dead dead."
- She informed Staff G that this was not how this situation should have been handled.

Based on interviews conducted with:
- Staff A, Chief Executive Officer;
- Staff C, ED Physician, ED Medical Director;
- Staff D, RN, Director of Emergency Services
- Staff E, Security Officer;
- Staff G, RN, ED Charge Nurse;
- Staff H, RN, ED Nurse,
- Staff F, RN, House Supervisor; and
- Staff I, Paramedic/ED Technician
Staff reported that Staff J, off-duty ED Physician, used his authority as a medical physician to prevent hospital staff from providing care, treatment or to transfer the patient inside to the ED. Staff reported that Staff J informed them that he was "in charge", he was a "physician" and it was his "call" therefore, staff did not feel that they had the authority not follow Staff J's orders when he "ordered" staff not to touch the body because it was a crime scene, not to initiate CPR on the body because the patient was "dead dead".

During a telephone interview on 09/23/20 at 11:42 AM, Staff O, on-duty ED Physician, stated that:
- When she reported for duty there were approximately 25 patients waiting in the ED, so she immediately began to treat patients.
- Sometime later in the shift she was informed by staff that a patient had been found down in the parking lot.
- She was informed that Staff J, off-duty ED Physician, was on-site and was in charge of the situation.
- Neither Staff J, off-duty ED Physician nor staff on the scene requested for her presence at the scene, therefore, she continued to see and care for patients in the ED.

Review of the Autopsy Report dated 07/19/19 showed:
- Findings: Severe coronary artery disease (CAD, narrowing of the arteries that limits blood flow to the heart that can lead to chest pain and/or a heart attack) with significant luminal (blood vessel) stenosis (abnormal narrowing of blood vessel) in the left anterior descending coronary artery. Severe coronary artery disease may result in sudden cardiac death due to arrhythmias, (a problem with the rate and/or rhythm of the heart).
- Cause of Death: Atherosclerotic Heart Disease (obstruction of blood flow to the heart).
- Manner of Death: Natural.

The facility failed to ensure that Patient #1 received a MSE to rule out if he experienced EMC that required emergent care/treatment when he presented on the hospital's premises.