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Based on policy review the hospital failed to provide, within its capability and capacity, an assessment and ongoing reassessment during a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (# 6), and failed to ensure an EMC was stabilized for one patient (#7) of 20 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed. These failed practices had the potential to cause harm to all patients who presented to the ED and L&D 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 emergency medical condition)," reviewed 02/2024, showed hospitals are required to provide a medical screening examination (MSE) to any individual who comes to the ED and requests an examination and/or treatment for an EMC. This applies to all individuals who present for emergency care, the hospital cannot refuse to examine or treat the individual. They must provide appropriate stabilization for the patient's EMC.

Review of the hospital's document titled, "Missouri Delta Medical Center Medical Staff - Rules and Regulations," adopted 04/06/06, showed:
- The hospital will provide an appropriate MSE within its capability, including ancillary services routinely available to the ED, for individuals requesting services. If an individual is unable to request services a request shall be deemed to have been made if a prudent layperson observer would believe, based on the individual's appearance or behavior, the individual needs services for a medical condition.
- An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual at risk of serious injury, serious impairment to bodily function or serious dysfunction of any bodily organ or part.
- If an EMC is found to exist, the hospital will provide necessary stablizing treatment or an appropriate transfer.
- Stabilizing treatment is considered as the treatment necessary to assure, within a reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a hospital.

Review of the hospital's policy titled, "MSE," reviewed 02/2024, showed any persons presenting to or being brought to the ED for unscheduled procedures or evaluation will receive a MSE by a physician utilizing ancillary services routinely available to the ED, including examination, testing, treatment and services of appropriate on-call physicians where indicated.

Please refer to A-2406 and A-2407 for further details.

Based on interview, record review and policy review the hospital failed to provide, within its capability and capacity, an assessment and ongoing reassessment during a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#6) of 20 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED and L&D unit 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 emergency medical condition)," reviewed 02/2024, showed, Hospitals are required to provide a medical screening examination (MSE) to any individual who comes to the ED and requests an examination and/or treatment for an EMC. This applies to all individuals who present for emergency care, the hospital cannot refuse to examine or treat the individual.

Review of the hospital's document titled, "Missouri Delta Medical Center Medical Staff - Rules and Regulations," adopted 04/06/06, showed:
- The hospital will provide an appropriate MSE within its capability, including ancillary services routinely available to the ED, for individuals requesting services. If an individual is unable to request services a request shall be deemed to have been made if a prudent layperson observer would believe, based on the individual's appearance or behavior, the individual needs services for a medical condition.
- An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual at risk of serious injury, serious impairment to bodily function or serious dysfunction of any bodily organ or part.
- If an EMC is found to exist, the hospital will provide necessary stabilizing treatment or an appropriate transfer.

Review of the hospital's policy titled, "MSE," reviewed 02/2024, showed any persons presenting to or being brought to the ED for unscheduled procedures or evaluation will receive a MSE by a physician utilizing ancillary services routinely available to the ED, including examination, testing, treatment and services of appropriate on-call physicians where indicated.

Review of Patient #6's medical record, dated 08/19/25, showed:
- She was a 36-year-old with no significant past medical history.
- At 7:41 AM, she presented to the ED accompanied by her supervisor after being hit in the head by a four-pound box at work earlier that morning. She reported pain, dizziness and vomiting after the incident. There was no loss of consciousness. She did have mild discoloration noted to the right upper forehead.
- Her vital signs (VS, measurements of the body's most basic functions) were normal, and her assessment was negative except for complaints related to her injury.
- At 8:04 AM, a triage pain assessment showed she reported head pain and rated it a seven on a one to 10 pain scale. There was no documentation of her pain being reassessed.
- A head 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) showed no acute process. She reported a persistent headache.
- There was no reassessment of nausea or dizziness documented in the medical record.
- There was no documentation in the medical record related to her ability to walk or tolerated oral intake.
- No medication was ordered or administered.
- Her discharge diagnosis was a head contusion.
- At 9:20 AM, she was discharged with instructions to follow up with her worker's compensation physician.

During an interview on 09/16/25 at 11:05 AM, Staff G, ED Medical Director, stated that she cared for Patient #6. The patient's injury appeared minor, but she ordered a head CT because the patient reported dizziness and vomiting after the incident. She did not recall that the patient had any difficulty ambulating or complained of nausea or vomiting after she presented to the ED. Her headache was minor, and she deferred treating it because it was not acute, and the patient was to see her worker's compensation physician after she was discharged. The pain would be treated with over-the-counter medication. She did not recall meeting with the patient's husband. The patient seemed satisfied with her care, although she seemed disappointed when informed of the negative results of the CT scan. The only dissatisfaction she was aware of occurred after discharge when the patient was in an outpatient lab to provide a sample for a urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) required by her employer, but she did not know the nature of it. She felt she provided an adequate MSE and determined an EMC was not evident.

During an interview on 09/16/25 at 11:55 AM, Staff M, CT Technician, stated that she recalled conducting Patient #6's CT scan but did not recall anything out of the ordinary. The patient did not vomit or appear to be in any distress. She arrived by wheelchair and was able to transfer herself onto the scanner. If the patient had difficulty transferring or reported any distress she would have contacted the ED nurse, but that was not necessary. She did not recall the husband being present.

During a telephone interview on 09/16/25 at 12:00 PM, Staff N, RN, stated that she cared for Patient #6 during her ED encounter. The patient presented after a workplace injury and wanted a CT of her head, which was completed. She did not recall a nausea complaint, and she did not witness any vomiting. The patient complained of a headache, but it was not acute, and the patient did not appear to be in distress. The patient was accompanied by her supervisor, and she did not recall if her husband was present. The physician saw the patient multiple times before she was discharged.

During a telephone interview on 09/6/25 at 3:40 PM, Staff O, RN, stated that he was in nursing orientation when he cared for Patient #6. He recalled her mentioning pain and nausea and thinks it was relayed to the physician, but no orders were received. The patient did not appear to be in distress or discomfort and mostly relaxed in bed. She was able to ambulate and transfer to and from the chair. He took the patient by wheelchair from the ED to the outpatient lab when she was discharged at the request of her husband, who did not think she should walk following a head injury. Staff O did not observe any vomiting during her stay.

Based on interview, record review and policy review the hospital failed to ensure an emergency medical condition (EMC) was stabilized for one patient (#7) of 20 Emergency Department (ED) and Labor and Delivery (L&D) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED and L&D unit 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 emergency medical condition)," reviewed 02/2024, showed, Hospitals are required to provide a medical screening examination (MSE) to any individual who comes to the ED and requests an examination and/or treatment for an EMC. This applies to all individuals who present for emergency care, the hospital cannot refuse to examine or treat the individual. They must provide appropriate stabilization for the patient's EMC.

Review of the hospital's document titled, "Missouri Delta Medical Center Medical Staff - Rules and Regulations," adopted 04/06/06, showed:
- The hospital will provide an appropriate MSE within its capability, including ancillary services routinely available to the ED, for individuals requesting services. If an individual is unable to request services a request shall be deemed to have been made if a prudent layperson observer would believe, based on the individual's appearance or behavior, the individual needs services for a medical condition.
- An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such as the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual at risk of serious injury, serious impairment to bodily function or serious dysfunction of any bodily organ or part.
- If an EMC is found to exist, the hospital will provide necessary stabilizing treatment or an appropriate transfer.
- Stabilizing treatment is considered as the treatment necessary to assure, within a reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a hospital.

Review of Patient #7's medical record, dated 07/19/25, showed:
- He was a 30-year-old with a past medical history of schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly) and frequent ED visits with behavioral health complaints.
- On 07/19/25 at 12:12 AM, he presented to the ED and stated that he needed to be admitted to a psychiatric (relating to mental illness) hospital because people were manipulating him, and he was seeing atypical colors. His initial exam indicated psychosis (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature).
- He was agreeable to a voluntary admission for psychiatric care and was medically cleared for admission to a psychiatric facility.
- At 3:50 AM, he received a psychiatric evaluation via telepsychiatry (telepsych, physician or health care provided psychiatric care through a camera and video monitor, while the health care provider is at a separate location) that found the patient had schizophrenia with evidence of psychiatric decompensation marked by resurgence of psychotic symptoms including paranoia (excessive suspiciousness without adequate cause), hallucinations (seeing or hearing things which are not there), delusions (false ideas about what is taking place or who one is) about his body, and functional decline. His condition appeared to worsen despite reported adherence to treatment, which rendered him unable to maintain safety or function independently. He posed no imminent danger to self or others but was gravely disabled due to the severity of his psychosis. He met the criteria for inpatient psychiatric admission.
- At 8:00 AM, the ED physician reviewed the patient with a psychiatrist from telepsych, the patient himself did not have decision making capacity at the time. A formal psychiatric consultation was planned for an involuntary admission.
- At 8:09 AM, the patient allowed to leave against medical advice (AMA).

Review of Patient #7's medical record, dated 07/20/25, showed:
- At 2:06 AM, he returned to the ED accompanied by family and reported hearing voices and requested to be "checked in somewhere to get help."
- Documentation indicated this was his tenth visit that month.
- A 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) was obtained.
- At 8:00 AM, he was transferred to a psychiatric hospital for treatment.

During a telephone interview on 09/16/25 at 11:40 AM, Staff K, Physician, stated that he treated Patient #7 after he presented to the ED on 07/19/25 until his shift ended at approximately 7:00 AM. The patient had agreed to a voluntary admission to a psychiatric hospital and was waiting for placement. He was not a threat to himself or others but could not take care of himself. He was in a room close to the nurses' station but not on continuous observation. Patients are not typically on continuous observation unless they are a threat to themselves or others. The patient should have been reassessed before being allowed to leave AMA.

During an interview on 09/16/25 at 11:50 AM, Staff L, Registered Nurse (RN), stated that at the time the patient left he was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), and did not express suicidal ideation (SI, thoughts of causing one's own death) or homicidal ideation (HI, thoughts or attempts to cause another's death). She notified the physician and charge nurse of the patient's intentions to leave AMA. Patient #7 refused to sign the AMA form.

During a telephone interview on 09/16/25 at 4:20 PM, Staff P, Physician, stated that he assumed care of Patient #7 at approximately 7:00 AM. He contacted a telepsych psychiatrist when the patient began to leave and was unable to reevaluate him before he left. Patient #7 did not pose imminent harm to himself or others and wished to leave. While he met the criteria for inpatient admission, he was unsure if he met the standard for an involuntary hold. Staff P was in the process of seeking advice from the psychiatrist when the patient left. He did not feel comfortable physically or chemically restraining (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) Patient #7.

During a telephone interview on 09/16/25 at 4:45 PM, Staff G, ED Medical Director, stated that it was the responsibility of the physician to reevaluate patients before they left AMA if there was a question about their capacity to make decisions or their safety. If the physician's judgment determined it was unsafe for the patient to leave, Public Safety Officers could detain the patient, and a court ordered hold could be sought.