Missouri Baptist Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 51292 Based on interview, record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate transfer sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#20) of 21 Emergency Department (ED) and Labor and Delivery records reviewed. 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): Barnes Jewish Children’s East,” dated 10/01/24, showed that an EMC means a medical condition manifesting itself by acute (sudden onset) symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to any bodily organ or part and if the patient is transferring from an ED and needs specialized care or treatment, the recipient hospital may not refuse to accept the transfer if the hospital has the capability and capacity to treat the patient. Please refer to 2411 for further details.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 51292 Based on interview, policy review and record review, the hospital failed to accept one patient (#20) from another hospital out of 21 Emergency Department (ED) records reviewed. The hospital’s ED average monthly census over the past six months was 4,076 Findings included: Review of Patient #20’s transfer request, dated 10/26/25, showed: - At 7:14 AM, a request for transfer was made by Staff O, Hospital B ED Physician, to the hospital’s transfer center (TC). The patient complained of severe flank pain (discomfort felt in the area between the ribs and the hip, can indicate infection in the kidney) and had been treated with Toradol (a powerful, prescription-only nonsteroidal anti-inflammatory drug [NSAID] used for the short-term relief of moderate to severe pain), morphine (an opioid pain medication), dilaudid (medication used to treat severe pain), and fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use). Her vital signs (VS, measurements of the body’s most basic functions) white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) were withing normal limits (WNL). A 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) of her abdomen and pelvis showed she had a seven millimeter (mm) kidney stone obstructing her right ureter (a duct or tube by which urine passes from the kidney to the bladder) with mild to moderate hydronephrosis (the swelling of one or both kidneys due to a backup of urine caused by an obstruction that causes intense pain, nausea, vomiting, fever and painful urination). A urinalysis (a laboratory examination of a person’s urine) had not yet been collected. - At 7:55 AM, a secure chat message (SCM) was initiated by the TC RN with Staff L, Urologist (a physician who specializes in diseases of the urinary system). - At 8:07 AM, the TC RN added Staff N, Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients), to the SCM. A brief history was provided. - At 8:47 AM, Staff N, Hospitalist, accepted the patient for transfer through SCM. Staff L, Urologist, indicated that no one had called him regarding the transfer. Staff L thought Patient #20 should be seen by the urologist who had previously treated her at Hospital B. The TC RN asked Staff L, if he wanted to speak with Staff O, ED Physician, but no response was recorded. - At 9:00 AM, Staff L, Urologist, documented that since Patient #20 was resting comfortably and her laboratory results were WNL, urologic surgery was not indicated. Patient #20 should continue care with her own urologist. The TC RN documented that she was informed that the urologist no longer worked at the hospital and asked if Staff L, Urologist, if he wanted to speak to the Staff O, ED Physician. Staff N, Hospitalist, volunteered to call him. - At 9:05 AM, Staff N, Hospitalist, called Staff O, ED Physician, who stated the transfer request was declined. - At 9:08 AM, the request for transfer was cancelled by the hospital’s TC RN. Review of Patient #20’s Hospital B medical record, dated 10/26/25, showed: - At 5:25 AM, she presented to the ED with severe right flank pain and nausea that had started the previous day. - Her medical history included kidney stones, chronic back pain, osteoarthritis (when the flexible tissue at the end of bones wears down and cause pain) and gastro-esophageal reflux disease (GERD, a digestive disease in which stomach acid or bile irritates the food pipe lining). - An abdominal CT showed she had a seven mm kidney stone obstructing her right ureter and other stones present in both kidneys. Her urinalysis showed the presence of WBC’s and red blood cells (RBC) in her urine. - She received several medications (Toradol, morphine, dilaudid, and fentanyl) before indicated that she was comfortable. Staff O, ED Physician, determined she needed to be hospitalized and monitored. - Since Hospital B did not urology on-call, a request to transfer for urology consult was initiated. The first request, to Hospital A, was declined. A second request was made to Hospital C and Patient #20 was accepted for transfer. Review of Patient #20’s Hospital C medical record, dated 10/26/25 showed: - At 11:33 AM, she was admitted as a transfer from Hospital B for on-going pain management, nausea and a urology consult. Urology ordered her to have nothing by mouth (NPO) after midnight in preparation for surgery the next day. - On 10/27/25 at 12:14 PM, Patient #20 underwent surgery for the kidney stone removal and stent placement (A tiny tube placed into an artery, a vein, or another structure such as the ureter [tube that carries urine] to hold the structure open). - At 5:32 PM, she was discharged home. Review of TC audio recording #1, dated 10/26/25, at 7:14 AM, showed Staff O, Hospital B ED provider, requested the transfer of Patient #20. Staff O relayed the patient’s medical history, current presentation and the request for transfer for continued treatment. Staff O reported Patient #20’s VS were stable, the interventions initiated for her comfort, and her comfort level. Laboratory results and CT results were provided to the TC RN. The TC RN indicated that she would be in touch once she had contacted the provider. The call ended. Review of TC audio recording #2, dated 10/26/25, at 7:55 AM, showed the TC RN contacted Staff O, Hospital B, ED Physician, to inform them that Staff L, Urologist, had reviewed the medical record and testing results for Patient #20. Staff L indicated that Patient #20 had previously seen a Urologist at Hospital B, and they wanted her to continue care with that provider. Staff O informed the TC RN that Patient #20’s previous Urologist no longer worked at the hospital. Hospital B did not have urology on-call. The TC RN asked for a moment to relay the information to Staff L, Urologist. She indicated she was “chatting with him now,” and letting him know that Patient #20’s former urologist no longer worked there. She explained she also asked Staff L, if he would talk to Staff O, ED Physician, directly because she did not “like to be in the middle of these things.” No response from Staff L was documented. The TC RN told Staff O that Staff L declined Patient #20’s transfer because her creatinine was normal, her WBC was normal, and urology surgery was not indicated that day. Staff L wanted Patient #20 to continue care with her own urologist. Staff O, ED Physician, told the TC RN that he had documented the refusal. The TC RN stated the hospitalist would be calling him shortly and the call ended. Review of TC audio recording #3, dated 10/26/25, at 8:07 AM, showed Staff N, Hospitalist, apologized for the declined transfer. Staff O, ED Physician, reiterated the reason the transfer was requested, and the call was ended. During an interview on 11/13/25 at 11:25 AM, Staff L, Urologist, stated that he received the request for transfer through a SCM and not a phone call. Transfer requests were not supposed to be initiated by SCM. He reviewed Patient #20’s medical record and saw that she had been seen a couple of years ago by a urologist at Hospital B. From his chart review, there was no indication for emergency surgery. He stated that he did not talk to Staff O, ED Physician, and did not actually tell the TC RN that he refused the transfer. During an interview on 11/13/25 at 11:45 AM, Staff M, ED Medical Director, stated that it was unclear whether Patient #20 had an EMC. She could have been discharged home to follow up with her own specialist. Transfer for pain control was not necessarily a higher level of care, because they could have managed her pain at Hospital B. He felt that the TC RN should have contacted the urologist first and then the hospitalist. He felt he did not have enough information to make a decision about Patient #20’s transfer request. During an interview on 11/13/25 at 12:00 PM, Staff N, Hospitalist, stated that she was contacted through a SCM about Patient #20. She was in a group message that included Staff L, Urologist, the TC RN, and herself. She did accept the patient initially, but once Staff L refused, she could not do anything. Staff O, ED Physician, was not available for interview.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 49404 Based on observation, interview, record review, and policy review, the hospital failed to ensure: - Patient identification and blood product verification were completed for one patient (#39) of three patients observed who received a blood transfusion (to administer blood into a vein); - Safe patient vital sign (VS, measurements of the body’s most basic functions) monitoring was completed per hospital policy for two patients (#11 and #42) of six patients reviewed who received a blood transfusion; and - A safe initial infusion rate for three patients (#11, #39, and #42) of six patients reviewed who received a blood transfusion. These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services. Please refer to A-0410.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 49404 Based on observation, interview, record review, and policy review, the hospital failed to ensure: - Patient identification and blood product verification were completed for one patient (#39) of three patients observed who received a blood transfusion (to administer blood into a vein); - Safe patient vital sign (VS, measurements of the body’s most basic functions) monitoring was completed per hospital policy for two patients (#11 and #42) of six patients reviewed who received a blood transfusion; and - A safe initial infusion rate for three patients (#11, #39, and #42) of six patients reviewed who received a blood transfusion. Findings included: Review of the hospital’s policy titled, “Blood Administration,” dated 06/19/24, showed: - VS were to be recorded no more than 30 minutes prior to the transfusion, 10 to15 minutes after the transfusion started, hourly throughout the transfusion, and within 30 minutes of the completion of the transfusion. - Blood transfusions were to start at a rate of 30 milliliters (ml) over 15 minutes (2 ml per minute or 120 ml per hour). - Staff were to remain with or be able to closely observe the patient for the first 15 minutes of the infusion to watch for adverse reactions. - Patient and blood component verification must be performed using the Electronic Medical Record (EMR) and the Blood Bank database. The recipient and unit information should be verified immediately before transfusion and in the presence of the recipient. The patient armband and barcodes on the blood component are scanned. The system should display a message notifying the transfusionist of the electronic verification. - The verification process must include patient identifiers on the blood component that matches the identity of the recipient, the recipient’s blood type, the unit’s identification number and blood type, and the unit’s expiration date/time. Observation on 02/04/25 at 1:30 PM, showed Staff U, Registered Nurse (RN), start a blood transfusion for Patient #39 at 1:40 PM. Blood reached the patient at 1:44 PM; the patient and blood product were scanned at 1:47 PM. The blood was started at a rate of 200 ml per hour. Review of Patient #42’s medical record, dated 01/20/25, showed the blood start rate of 150 ml per hour. Blood was started at 12:40 PM and ended at 3:20 PM. VS were recorded at 12:40 PM, 12:55 PM, and 3:20 PM, no hourly vital signs were recorded between 12:55 PM and 3:20 PM. Review of Patient #11’s medical record, dated 02/03/25, showed the blood start rate of 30 ml per hour. Blood was started at 12:27 PM, no VS were recorded until 12:44 PM. During an interview on 02/04/25 at 4:10 PM, Staff U, RN, stated that she scanned Patient #39’s blood after the transfusion began. She had read the patient’s name on the blood product label before starting the transfusion. Patients and blood components should be scanned before administration and made a mistake. During an interview on 02/04/25 at 3:30 PM, Staff G, Nurse Manager, stated that she expected patients and blood product components to be scanned prior to administration. The initial transfusion rate should comply with the policy. Administering blood products before the patient and blood component were scanned put the patient at risk of receiving incompatible blood. The starting time for blood was when the blood reached the patient. During an interview on 02/06/25 at 9:00 AM, Staff B, Assistant Chief Nursing Officer, stated that she expected patients and blood products to be scanned before administration. The start rate should be 120 ml per hour and vital signs to be documented per policy.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 39354 Based on record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#13) of 23 Emergency Department (ED) records reviewed. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital’s average monthly ED census over the past six months was 3,668. Findings included: Review of the hospital’s undated policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy,” showed that when an individual presents to the ED and requests examination or treatment for a medical condition, the hospital must provide an appropriate MSE by qualified personnel as determined by the board of directors. The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether or not an EMC exists. Review of the hospital’s policy titled, “Rules and Regulations of the Medical Staff,” dated 03/18/23, showed that for MSEs, any individual presenting to the ED requesting examination or treatment would receive a MSE to determine if the individual had an EMC as required by federal law. Physicians, registered nurses (RNs), advanced practice registered nurses, physician assistants, and for psychiatric (relating to mental illness) evaluations, mental health coordinators, were authorized to perform a MSE. Only physicians were authorized to certify an unstable patient for transfer. All patients admitted to the ED would be assessed by a RN or physician prior to discharge. Patient #13 presented to the ED on 08/20/23, with complaints of nausea, vomiting, and difficulty swallowing for the past five days. She had a history of dysphagia (difficulty or discomfort with swallowing). She was triaged (process of determining the priority of a patient’s treatment based on the severity of their condition), with vital signs (body temperature, blood pressure, heart rate, and breathing rate) of a temperature of 98.2 degrees Fahrenheit, pulse rate (the number of heart beats per minute) of 112, respirations (inhalation and exhalation of air; breathing) of 12 breaths per minute, blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) of 123/98, and oxygen saturation (measure of how much oxygen was in blood) of 100%. During the Nurse Practicioner (NP) evaluation, the NP documented the patient voiced she had a condition called Achalasia (rare disorder that makes it difficult for food and liquid to pass from the swallowing tube connecting your mouth and stomach) and often had difficulty swallowing food due to sphincter constriction. During her ED evaluation, the RN documented the patient stated she had not been able to keep any food/water down for five to seven days. No other ancillary testing was done. She was discharged with a prescription for Reglan (a medication used to prevent nausea and vomiting) 10 milligrams (mg, a measure of dosage strength), one tablet by mouth every six hours. She then presented to Hospital E and after completing her MSE, including blood work, the patient was admitted as an inpatient, where she remained until 08/26/23 for dysphagia, nausea, vomiting, and dehydration (a condition caused by excessive loss of water from the body).”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 39354 Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#13) of 23 Emergency Department (ED) records reviewed. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital’s average monthly ED census over the past six months was 3,668. Findings included: Review of the hospital’s undated policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy,” showed that when an individual presents to the ED and requests examination or treatment for a medical condition, the hospital must provide an appropriate MSE by qualified personnel as determined by the board of directors. The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether or not an EMC exists. Review of the hospital’s policy titled, “Rules and Regulations of the Medical Staff,” dated 03/18/23, showed that for MSEs, any individual presenting to the ED requesting examination or treatment would receive a MSE to determine if the individual had an EMC as required by federal law. Physicians, registered nurses (RNs), advanced practice registered nurses, physician assistants, and, for psychiatric (relating to mental illness) evaluations, mental health coordinators, were authorized to perform a MSE. Only physicians were authorized to certify an unstable patient for transfer. All patients admitted to the ED would be assessed by a RN or physician prior to discharge. Review of Patient #13’s medical record from Hospital A, dated 08/20/23, showed the following: - She was a 27-year-old female who presented to the ED at 10:24 AM, with nausea, vomiting, and difficulty swallowing for the past five days. - She had a history of dysphagia (difficulty or discomfort with swallowing). - At 10:25 AM, she was triaged (process of determining the priority of a patient’s treatment based on the severity of their condition), with vital signs (body temperature, blood pressure, heart rate, and breathing rate) of a temperature of 98.2 degrees Fahrenheit, pulse (the number of heart beats per minute) of 112, a respiratory rate (inhalation and exhalation of air; breathing) of 12 breaths per minute, blood pressure (BP, a measurement of the force of blood pushing against the walls of the arteries at two different times during a heartbeat, normal is approximately 90/60 to 120/80) of 123/98, and oxygen saturation (measure of how much oxygen was in blood) of 100%. - At 10:31 AM, Staff S, Nurse Practitioner (NP), evaluated Patient #13. During the Nurse Practicioner (NP) evaluation, the NP documented the patient voiced she had a condition called Achalasia (rare disorder that makes it difficult for food and liquid to pass from the swallowing tube connecting your mouth and stomach) and often had difficulty swallowing food due to sphincter constriction. - At 11:06 AM, nursing documentation showed that Patient #13 stated she had not been able to keep any food/water down for five to seven days. - At 11:26 AM, she was set for discharge and no labs had been ordered. - At 11:27 AM, she was given a prescription for Reglan (a medication used to prevent nausea and vomiting) 10 milligrams (mg, a measure of dosage strength), one tablet by mouth every six hours. - At 11:42 AM, Patient #13 was discharged from the ED. During an interview on 11/08/23 at 11:53 AM, Staff S, NP, stated that she did not recall Patient #13, however, if a patient presented to the ED with nausea, vomiting, and difficulty swallowing, she would assess the patient to see why they had nausea, vomiting, and difficulty swallowing before she put in any orders. If the patient were stable, they would not necessarily get an intravenous (IV, in the vein) and get labs drawn. From the patients chart, the patient’s vital signs were stable so she did not present as dehydrated. Patient #13 did not seem to be urgent and had a plan in place for further treatment. During an interview on 11/07/23 at 1:50 PM, Staff J, ED Assistant Nurse Manager, stated that if a patient presented to the ED with dysphagia, nausea and vomiting, they would typically order basic labs included in the abdominal pain standing orders. Basic labs included a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), a comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions), and a lipase (a test that measured the level of enzymes in your blood). During an interview on 11/07/23 at 3:07 PM, Staff N, ED RN, stated that he was Patient #13’s triage nurse. The patient presented with nausea and vomiting and could not hold down food for a long period of time. After he had the patient triaged, she went to the waiting room for only a short period of time. They did not use standing orders when a patient went back to a room quickly. During an interview on 11/07/23 at 2:25 PM, Staff L, ED RN, stated that she remembered Patient #13. The patient was taken straight back from triage and hooked up to the machine to monitor her BP and oxygen. The NP went into the room to see the patient. The patient complained of abdominal pain and vomiting. When the ED was slow, ED standing orders were not used. Orders were not put in until after the patient was seen by the provider. The NP ordered the patient Reglan. If the standing orders were not used, labs or IVs were not started until the provider ordered them. Review of Patient #13’s medical record from Hospital E, dated 08/20/23, showed the following: - She presented to the ED with a chief complaint of nausea and vomiting at 12:46 PM. - The patient reported a past medical history of dysphagia, had not been able to tolerate anything by mouth for the past five days, and had been to Hospital A earlier that day. - Blood work results showed a blood glucose (sugar) of 59 (normal range 70-99); chloride (a type of electrolyte in the blood, normal range was 96-106) of 108; carbon dioxide (CO2, a gas produced by exhaling, normal range was 23-29) of 12; red blood cell count (RBC, the number of red cells [oxygen carrying cells] in the blood, normal range was 4.2-5.4) of 5.87; hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body, normal range was 12-16) of 15.9; and hematocrit (a blood test that measures how much of a person’s blood was made up of red blood cells, normal range was 36-48) of 49.5. - On 08/20/23 the patient was admitted with diagnoses that included dysphagia, nausea, vomiting, and dehydration (a condition caused by excessive loss of water from the body), she remained an inpatient until 08/26/23 receiving IV medication, further evaluation and treatment.”