Parkland Health 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: 48359 Based on policy review the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for two patients (#9 and #12) and arrange an appropriate transfer for one patient (#6) of 32 ED medical records reviewed from 01/01/26 through 03/09/26. These failed practices had the potential to cause harm to all patients who presented to the ED 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 EMC),” published 12/16/25, showed: - MSE is an examination sufficient to reasonably indicate the presence or absence of EMC for an individual. - When an individual comes to the ED and requests emergency care or treatment the hospital must provide an appropriate MSE (beyond medical triage [process of determining the priority of a patient’s treatment based on the severity of their condition]) by qualified medical personnel (physicians, non-physician advanced providers and Registered Nurses [RN]) as determined by the medical staff and hospital board of directors. - The MSE must be within the hospital’s capacity and capability and include ancillary services routinely available to determine if an EMC exists. - The hospital must follow guidelines that honor all requests for examination or treatment; utilize the routinely available ancillary services to conduct the MSE; and no patient will be discharged or transferred without a MSE. - Once the determination is made that the individual has an EMC, the hospital must provide either further examination or treatment as may be required to stabilize the medical condition, or transfer of the individual to another medical facility in accordance with the regulations. - When an individual is determined to have an EMC, the hospital will follow established protocols for appropriate transfer of the patient to another medical facility if indicated or if requested by the patient. Review of the hospital’s policy titled, “Suicide (to cause one’s own death) Prevention,” published 01/23/26, showed: - Patients have the right to be safe in the hospital. Patients who have had suicidal ideation (SI, thoughts of causing one’s own death) or with suicidal behaviors need additional individualized precautions implemented to keep them safe. - All patients twelve years old and older are to be evaluated and treated for behavioral health (BH) conditions as their primary reason for care including patients in the ED. All patients will be screened for SI. - Patients who are unable to answer the questions due to decreased mental status or an unstable medical condition will be screened when clinically appropriate. - The provider or Qualified Mental Health Professional (QMPH) will complete an evidence-based suicide risk assessment when the patient is appropriate for further assessment to include sobriety reached. - The assessment directly asks about SI, plan, intent, suicidal or self-harm behaviors, risk factors and protective factors. - This overall level of risk must be clearly documented, with clinical justification as well as the plan to mitigate the risk for suicide. Review of the hospital’s policy titled, “BH Assessment by BJC Behavioral Health in ED,” published 01/13/26, showed: - The ED provider completes the MSE per the EMTALA policy. When an individual comes to the ED the attending provider must make the determination for psychiatric assessment. - The BH Navigator will review the medical record and then assign a QMHP to proceed on completing the assessment. The patient should constantly be observed for safety or a one to one (1:1, continuous visual contact with close physical proximity) sitter present. - If a provider does not order a BH assessment or substance use assessment as indicated by the MSE, the charge nurse should be notified. - After completing the assessment, the QMHP will communicate the evaluation results and findings to both the treating RN and the assigned provider. Please refer to A-2406 and A-2409 for further details.”

“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: 48359 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for two patients (#9 and #12) of 32 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED with 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),” published 12/16/25, showed: - MSE is an examination sufficient to reasonably indicate the presence or absence of an EMC for an individual. - When an individual comes to the ED and requests emergency care or treatment the hospital must provide an appropriate MSE (beyond medical triage [process of determining the priority of a patient’s treatment based on the severity of their condition]) by qualified medical personnel (physicians, non-physician advanced providers and Registered Nurses [RNs]) as determined by the medical staff and hospital board of directors. - The MSE must be within the hospital’s capacity and capability and include ancillary services routinely available to determine if an EMC exists. - The hospital must follow guidelines that honor all requests for examination or treatment; utilize the routinely available ancillary services to conduct the MSE; and no patient will be discharged or transferred without a MSE. Review of the hospital’s policy titled, “Suicide (to cause one’s own death) Prevention,” published 01/23/26, showed: - Patients have the right to be safe in the hospital. Patients who have had suicidal ideation (SI, thoughts of causing one’s own death) or with suicidal behaviors need additional individualized precautions implemented to keep them safe. - All patients twelve years old and older are to be evaluated and treated for behavioral health (BH) conditions as their primary reason for care including patients in the ED. All patients will be screened for SI. - Patients who are unable to answer the questions due to decreased mental status or an unstable medical condition will be screened when clinically appropriate. - The provider or Qualified Mental Health Professional (QMPH) will complete an evidence-based suicide risk assessment when the patient is appropriate for further assessment to include sobriety reached. - The assessment directly asks about SI, plan, intent, suicidal or self-harm behaviors, risk factors and protective factors. - This overall level of risk must be clearly documented, with clinical justification as well as the plan to mitigate the risk for suicide. Review of the hospital’s policy titled, “BH Assessment by BJC Behavioral Health in ED,” published 01/13/26, showed: - The ED provider completes the MSE per the EMTALA policy. When an individual comes to the ED the attending provider must make the determination for psychiatric (relating to mental illness) assessment. - The BH Navigator will review the medical record and then assign a QMHP to proceed on completing the assessment. The patient should constantly be observed for safety or a one to one (1:1, continuous visual contact with close physical proximity) sitter present. - If a provider does not order a BH assessment or substance use assessment as indicated by the MSE, the charge nurse should be notified. - After completing the assessment, the QMHP will communicate the evaluation results and findings to both the treating RN and the assigned provider. Review of Patient #9’s medical record dated 01/03/26, showed: - At 4:06 PM, he was a 44-year-old who presented to the ED with cough, shortness of breath and extreme fatigue (weakness or tiredness). - The patient’s wife reported the patient had an upper respiratory infection (URI, irritation and swelling of the upper airways with associated cough and nasal congestion) in 10/2025 and had not fully recovered. He had a productive cough of green sputum (a mixture of saliva and mucous) and his oxygen saturation (SAO2, measure of how much oxygen is in blood, normal is 95% to 100%) had been 85% at home. She stated he was very fatigued and wondered if his carbon dioxide (CO2, a gas produced by exhaling) was elevated. - His wife reported he had a decubitus ulcer (injury to the skin and underlying tissues caused by prolonged pressure; also knows as a bedsore or pressure sore) on his sacrum (triangular shaped bone above the tailbone) that was scheduled for debridement (the removal of damaged tissue or debris from a wound) on 01/08/26, which she wanted evaluated in the ED. - His past medical history included quadriplegia (the loss of the ability to use both arms and legs, typically caused by a spinal cord injury) since 07/2014, traumatic brain injury (TBI, an injury in how the brain works), acute (sudden onset) metabolic encephalopathy (a disease in which the functioning of the brain is affected by an illness or organs that are not working as well as they should, such as with a viral infection or toxins in the blood), acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (not enough oxygen reaching the cells and tissues in the body) and hypercapnia (when you have too much CO2 in your blood), chronic (long-term, on-going) osteomyelitis (infection of the bone) of the pelvis (area of the body below the abdomen), complicated urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra), decubitus ulcer, multi-drug resistant organism (MDRO; bacteria resistant to many antibiotics) resistance, sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs) and diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing). He had a chronic suprapubic catheter (a hollow flexible tube inserted through the skin of the lower abdomen, a few inches below the navel and into the bladder used to drain urine from the body). - The physical exam showed his skin was warm and dry. There was no assessment of a decubitus ulcer. - At 4:16 PM, a triage (process of determining the priority of a patient’s treatment based on the severity of their condition) note showed the patient’s wife stated that she thought his CO2 may have been high because he kept falling asleep. - At 4:20 PM, his vital signs (VS, measurements of the body’s most basic functions: Include blood pressure [BP] normal between 90/60 and 120/80; pulse/heartbeats [HR] normal 60 to 100 per minute; respiration rate [RR] normal 12 to 20 breaths per minute; and body temperature [T]normal 97.8o to 99o Fahrenheit [F]) were T 97.6o F, HR 82, RR 20, BP 105/62 and SAO2 89% on room air. - At 4:21 PM, his SAO2 was 98% after oxygen was applied at three liters per nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen). - From 4:21 to 9:02 PM, his VS were T 98.0o F, HR 88 to 114, RR 11 to 20, BP 108/60 to 124/76 and SAO2 93% to 98%. - At 5:26 PM, the nursing neurological (neuro, relating to or affecting the nervous system) examination showed he was drowsy but arousable to voice. - At 5:29 PM, his complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) showed his white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 3.8 to 9.9) was 13.57. - At 5:32 PM, his ABGs showed his partial pressure of carbon dioxide (PCO2, measurement of the amount of CO2 dissolved in your blood, normal is 35 to 45) was 61, total CO2 (assessment of the blood’s pH and electrolyte [minerals in the blood and other body fluids that carry an electric charge] balance, normal is 21 to 30) was 39 and bicarbonate (HCO3, chemical in the body that stabilizes pH levels, normal is 20 to 30) was 32. He remained on three liters of oxygen via NC. - At 5:46 PM, blood cultures (a laboratory test to check for bacteria or other germs in a blood sample) were drawn. His troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 22) was 48. - At 5:47 PM, his comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) was unremarkable. - At 6:38 PM, an electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed sinus tachycardia (a rapid, regular heart rhythm over 100 beats per minute). - At 6:58 PM, the nursing skin assessment showed a stage two decubitus ulcer (a shallow opening in the skin with red or pink tissue or may present as a fluid filled blister) to his right buttock and a non-stageable decubitus ulcer to his left gluteal fold (area where the lower buttock meets the top of the leg). - At 7:36 PM, his blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health, normal is 80 to 199) was 109. - At 7:48 PM, a chest computed tomography (CT, a combination of x-rays and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan showed no definite significant pulmonary embolism (PE, blood clot in the lung), right heart strain, acute infiltrate (accumulation of a foreign substance, typically within the lungs) or acute effusion (fluid build-up within the space between the lung and the chest wall). An abdominal and pelvis CT showed no definite acute findings. - At 7:56 PM, his two-hour troponin showed 45 with a delta troponin (change in troponin value from the most recent previous value) of -3, interpreted as insignificant. - Staff F, Nurse Practitioner (NP, a nurse with advanced clinical education and training), documented labs were reviewed and notable for a WBC of 13.57 and troponin of 48 and 45. - A progress note showed there were no acute findings on his work up. The patient reported chronic sinus drainage which was suspected as a sinus infection causing his cough. He was recommended to follow up with his primary care physician (PCP) or an ear, nose, and throat (ENT, a surgical subspeciality within medicine that deals with the surgical and medical management of conditions of the head and neck) provider. - At 9:02 PM, he was diagnosed with a sinus infection and discharged to home with prescriptions for doxycycline (antibiotic) and probiotics (medication with healthy bacteria that support digestive health). - A urinalysis (UA, a laboratory examination of a person’s urine) was not performed. Review of Patient #9’s Hospital C, Critical Access Hospital (CAH), medical record dated 01/05/26, showed: - At 9:59 AM, he presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) with a chief complaint of shortness of breath. - His UA was positive for nitrites (a chemical compound not normally found in urine, that indicates a bacterial UTI). - A chest CT scan showed right lower lobe infiltrates. - At 1:10 PM, he was intubated (process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) for respiratory insufficiency (a condition where the lungs cannot properly exchange oxygen and carbon dioxide, leading to breathing difficulties), altered mental status (AMS, mental functioning ranging from slight confusion to coma) and a need for airway protection. - Patient #9 was transferred to Hospital B, Acute Care Hospital, for an impression of acute on chronic respiratory failure with hypercapnia, low blood sugar and AMS. Review of Patient #9’s Hospital B medical record dated 01/05/26, showed he was received in the ED from Hospital C and admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) with a diagnosis of acute on chronic respiratory failure with hypoxia and hypercapnia, pneumonia (infection in the lungs) and severe sepsis. During a telephone interview on 03/12/26 at 8:40 AM, Staff F, NP, stated that she was confused by Patient #9’s ED visit for being drowsy because his mentation was normal. She remembered the family “kept saying he was so drowsy,” but he was alert and oriented. She did not observe a cough or sputum during her examination. She did not perform a UA because he had no urinary complaints, no belly pain and suprapubic catheters “come back contaminated.” She reviewed the ABGs, and the patient had chronic hypercapnia. The abdominal and pelvis CT scan was completed to assess his wounds and showed no osteomyelitis. If his WBCs had been 18 or 20, she would have done a further work up. She did not recall if he was discharged on oxygen or if an attempt was made to wean the oxygen. She felt his work up was thorough and could not think of what else she would have done. During a telephone interview on 03/17/28 at 1:34 PM, Staff G, Registered Nurse (RN), stated that he would not discharge a patient with a subtherapeutic SAO2 but could not recall if Patient #9 was discharged on oxygen. “On a good day in the ED,” he would have documented the weaning of oxygen. He was expected to document when oxygen was weaned. Patient #9 was “kind of a fragile guy with his wounds and quadriplegia.” His assessment of drowsy meant the patient was mildly somnolent (sleepy, drowsy), easily arousable with appropriate interactions. He was surprised a UA was not performed. He stated that “it had to be a stupid day,” in the ED because he would have normally asked for a UA. During a telephone interview on 03/17/25 at 3:30 PM, Staff B, Chief Nursing Officer (CNO), stated that she expected a full systems assessment for ED patients. She expected a UA for a patient with a suprapubic catheter with a complaint of drowsiness. She expected the provider to document direct assessment of wounds or review of the nursing wound assessment documentation. During a telephone interview on 03/18/26 at 9:00 AM, Staff O, ED Manager, stated that she expected oxygen management was documented. She expected provider documentation of a patient’s wound if the family requested a wound assessment. A provider should document what was assessed. She was surprised a UA was not ordered considering the patients suprapubic catheter and elevated WBCs. Review of the hospital’s document titled, “EMS trip ticket,” dated 01/12/26, showed EMS was dispatched for a psychiatric case, Patient #12 was suicidal yelling at customers. Upon arrival she was found lying on the concrete rolling around. Law enforcement was present because she was causing a nuisance. EMS was aware of her past history as they had responded numerous times prior, and she had a history of alcohol abuse. When asked if she was suicidal, she stated “yes.” They asked her if she had a plan and she stated, “yes I want to take fentanyl to kill myself.” Documentation showed she began to get agitated and aggressive on the way to the hospital. Review of Patient #12’s medical record dated 01/12/26, showed: - She was a 39-year-old who presented to the ED via EMS. She was found intoxicated laying outside. - Her past medical history included anxiety, depression (extreme sadness that doesn’t go away), mania (a period of time when a person cannot sleep for days, feels elevated and grandiose, and is easily distracted) and Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock). - At 12:45 PM, her VS showed BP 114/74, RR 20 and HR 88. - At 12:52 PM, a Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life) was completed. Patient #12 answered yes to all questions which made her a high risk for SI. - At 12:52 PM, elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury) and a 1:1 were initiated. - At 1:13 PM, an intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) was placed, lab work that included a CBC, CMP and blood alcohol were completed. - At 1:19 PM, Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) five milligrams (mg) was administered intramuscularly (IM, within the muscle) and lorazepam (a medication used to treat anxiety or sleep difficulty) one mg intravenous (IV, in the vein) was administered. - At 1:14 PM, a consult was initiated for a social worker and for a mental health (MH) evaluation. - At 1:36 PM, Staff Q, Physician, documentation showed she had a history of alcohol abuse, was well known to the ED and was homeless, who presented after being found intoxicated on the street. EMS reported that she complained of abdominal pain however in the ED she was verbally abusive. She was obviously intoxicated, and she became physically abusive to staff. - Her physical examination showed she was generally in a very poor state of health, obviously intoxicated, remarkably verbally and physically aggressive and abusive to staff. - The patient required restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and was subsequently provided medications to treat her agitation. - At 3:25 PM, her blood alcohol level was 283 (normal was less than 10) and her potassium (mineral in the blood or body fluid) was 2.9 (normal range 3.3 - 4.5). - At 4:20 PM, the patient was unable to take potassium by mouth. She was sleeping after receiving medications. - At 4:35 PM, fall precautions were initiated. - VS were monitored every 30 minutes throughout the course of her stay. Her HR began to fall to less than 60 following the administration of Haldol and lorazepam. - At 5:00 PM, her HR was 39. Her HR had been in the 30’s to 40’s since 1:15 PM. - At 6:13 PM, Staff Q, documented Patient #12 quit drinking alcohol, she remained calm for the last three or four hours. She was medically stable for discharge. - At 6:15 PM, her HR was 43. - At 6:25 PM, her personal belongings were returned. A sandwich tray and a bottle of water were provided. Discharge education was completed. She refused the potassium. - At 6:21 PM, she was awoken for reassessment. She denied homicidal ideation (HI, thoughts or attempts to cause another’s death) and SI. - She cursed at staff while being asked to get dressed. Security presented in case they were needed. - She was given discharge instructions and discharged. - At 6:41 PM, Patient #12 was sleepy and continued to fall asleep. Continued efforts were made to wake her up. She was eating a sandwich intermittently. - At 7:00 PM, she was discharged via a private vehicle. - There was no documentation of a MH assessment, no documentation that showed justification for not obtaining a MH assessment, she was discharged with a HR ranging in the 30’s and 40’s and no documentation from the social worker consult. Review of hospital document titled, “Affidavit (a written statement confirmed by oath, for use as evidence in court) in support of application for detention, evaluation and treatment/rehabilitation admission for 96 hours,” dated 01/12/26, showed, the patient told EMS personnel that she wanted to take fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) in attempt to kill herself. During an interview on 03/13/26 at 11:00 AM, Staff R, RN, stated that she was assigned as Patient #12’s nurse on 01/12/26. She was very abusive to staff both verbally and physically. “Everyone knows who she is, she comes in all the time drunk and out of control, belligerent and kicking staff.” The CSSR was completed when she was intoxicated, and she answered yes to all the questions. She was coherent and “not suicidal when she was discharged.” “I had to go in and keep waking her up, she would take a bite and then went back to sleep, the third time I told her this was it she was leaving. I got her dressed and gave her food and her sleeping bag.” She was escorted out of the building by security following discharge. She stated that she followed orders from the physician and if a MH assessment was not completed the physician had evaluated her and decided she did not need it. She stated the physician was aware of her VS when discharged. She did not recall any family present. When asked how she left via private vehicle when she arrived by ambulance, she was not sure “Maybe she had family there, I don’t know I did not check, she was stable, and it was time for her to go.” During a telephone interview on 03/12/26 at 4:30 PM, Staff Q, Physician, stated that Patient #12 had verbally and physically assaulted the ED staff when she presented to the ED. He stated, “she was well known in the ED.” Patient #12 was homeless and frequently came in drunk. “I did not get a BH assessment with psychiatry, I did not need one she was just drunk. She was placed on a 1:1, I completed a SI assessment when she sobered up, but I didn’t document it.” He stated the nurse documented she was not SI or HI. He did not know where Patient #12 was going after discharge or if anyone was picking her up. The nurse handled those details. He gave her medication and just let her sleep it off. She was stable for discharge, the BH assessment was cancelled, and he discharged her. He did not recall her low HR but again stated she was stable. He stated she did go back the next day and they did a complete BH assessment then. Although requested, the second medical record was not received. During a telephone interview on 03/11/26 at 2:25 PM, Staff O, ED Manager, stated that she expected the provider to complete a BH assessment and document all BH assessments. She expected the provider’s documentation to include the justification for being stable for discharge. If a patient was intoxicated, she expected to see documentation to support the patient was clinically sober. If a patient had answered yes to the CSSR questions she expected documentation to support a BH assessment or documentation of a SI assessment to show that the patient was not currently SI or HI. She declined to answer questions regarding the low HR of Patient #12 and stated, “it was a physician’s call to discharge.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to arrange an appropriate transfer for one patient (#6) of 32 Emergency Department medical records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED with an emergency medical condition (EMC) in need of a transfer. 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),” published 12/16/25, showed when an individual is determined to have an EMC the hospital will follow established protocols for appropriate transfer of the patient to another medical facility if indicated or if requested by the patient. Review of the cardiology on-call schedule for 02/03/26 showed Staff P, Cardiologist, was on call to the ED. Review of Patient #6’s medical record dated 02/03/26, showed: - At 9:36 PM, he presented to the ED with a chief complaint of chest pain, associated with a rapid heart rate, that he was able to interrupt twice with a vagal maneuver (a simple, self-administered techniques to stimulate the vagus nerve [a nerve that controls involuntary bodily functions such as heart rate [HR] and respiratory rate [RR]). A third recurrence led to chest discomfort and minimal shortness of breath. The patient stated that he had a history of coronary disease (when fatty deposits build up in the arteries, narrowing them and restricting blood flow to the heart) with multiple stents (tiny tubes placed into an artery or vein to hold the structure open), but noted that within the last couple of months had a cardiac catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions) which showed no occlusive disease that required intervention. - Additional past medical history included high blood pressure, chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing) and ventricular dysrhythmias (an abnormal electrical signal in the heart’s lower chambers that cause it to beat too fast, chaotically or ineffectively). - A review of systems showed he had shortness of breath, chest pain and palpitations (a sensation that the heart is racing, pounding, fluttering, or skipping a beat). - The physical examination showed he had tachycardia (abnormally rapid heart rate, greater than 100 beats per minute). - The triage (process of determining the priority of a patient’s treatment based on the severity of their condition) note showed the patient spoke to cardiology at Hospital B, Acute Care Hospital, that morning, and it was recommended if his HR continued to rise, he should go in and get an extra dose of amiodarone (medication used to treat heart rhythm problems). - At 9:39 PM, an order was placed for oxygen at two liters via a nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen). - At 9:44 PM, his electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed tachycardia suspicious for atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow). - At 9:46 PM, his vital signs (VS, measurements of the body’s most basic functions: blood pressure [BP] normal between 90/60 and 120/80; HR normal 60 to 100 per minute; RR normal 12 to 20 breaths per minute; and body temperature [T] normal 97.8o to 99o Fahrenheit [F]) were T 97.4 F, RR 20, HR 145 and BP 129/85. His oxygen saturation (SAO2, measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) was 90%. - At 9:48 PM, his pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was seven for chest pain. No additional pain scale assessments were performed. - At 9:50 PM, a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) were unremarkable. - From 9:50 PM to 9:59 PM, his VS were HR 97 to 146, RR 18 to 20 and SAO2 89% to 91%. - At 9:50 PM and 11:31 PM, his troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less 22) was 18. - At 9:54 PM, aspirin (blood thinner that can also treat pain, fever, headache and inflammation) and intravenous (IV, in the vein) amiodarone were administered. - At 10:00 PM, carvedilol (used to treat high blood pressure and heart failure [heart cannot pump or fill adequately]) was administered. - From 10:00 PM to 02/04/26 at 3:16 AM, his VS were HR 60 to 78, RR 15 to 24, BP 109/73 to 139/82, and SAO2 88% to 96%. - At 10:05 PM, his EKG showed sinus rhythm (healthy, regular heartbeat). - At 10:13 PM, a chest x-ray (test that creates pictures of the structures inside the body-particularly bones) showed cardiomegaly (a disease in which the heart muscle weakens and becomes enlarged making it hard to deliver blood to the rest of the body). - On 02/04/26 at 12:50 AM, a nursing cardiac assessment showed a regular HR. - At 1:51 AM, his troponin was 19. - The medical decision making showed he was hemodynamically stable (a person’s heart is pumping blood effectively, their BP is consistent, and their circulation is sufficient to supply oxygen to vital organs). He converted to sinus rhythm with a single bolus (large volume) of amiodarone, and he was on amiodarone at his baseline. His troponins were negative, and he had no metabolic derangement. He was a planned transfer to Hospital B for the need of cardiology (a branch of medicine concerned with the study and treatment of heart disorders) electrophysiology (a subspecialty focused on diagnosing and treating heart rhythm disorders) and cardiology continuity of care. - At 3:20 AM, Patient #6 was transferred to Hospital B via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.). - The on-call cardiologist (a physician that specializes in the care of your heart and blood vessels) was not consulted. - There was no documentation to indicate the patient requested a transfer to Hospital B. Review of Patient #6’s Hospital B medical record dated 02/04/26, showed: - He was a direct admission from Hospital A for escalation of care due to chest pain and ventricular tachycardia (a condition in which the lower chambers of the heart [ventricles] beat very quickly). - His VS were BP 145/86, T 98.3 F, HR 64, RR 23 and SAO2 91%. - The discharge summary showed no resolved problems to display. - The hospital course showed review of EKG notable for atrial tachycardia (a condition in which the upper chambers of the heart [atria] beat very quickly) with aberrant conduction (a temporary interruption in the heart’s electrical system) with known right bundle branch block (condition caused by a blocked electrical pathway in the heart). Amiodarone increased and carvedilol changed to metoprolol (a medication used to treat high blood pressure and chest pain). Episodes of tachycardia associated chest pain resolved with medication changes. Review of Patient #6’s chest x-ray dated 05/15/23, showed cardiomegaly. During a telephone interview on 03/17/26 at 9:00 AM, Staff H, Physician, stated that once Patient #6 cardioverted he was stable. Patient #6 was well established with cardiology at Hospital B and Staff H believed the patient requested transfer to Hospital B, but he did not document that. He did not consult Staff H, because there was not a good reason to wake him up if the patient was going to be transferred. During a telephone interview on 03/17/26 at 3:30 PM, Staff B, Chief Nursing Officer (CNO), stated that she believed Hospital B did not have cardiology electrophysiology which she believed Patient #6 could have completed as an outpatient. She stated that it was “best practice” for the ED provider to consult the in house on call specialist. During a telephone interview on 03/18/26 at 9:00 AM, Staff O, ED Manager, stated that she expected a provider to document when a patient requested a transfer. She expected the on-call specialist to be consulted if the patient did not request a transfer.”

“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: 48359 Based on policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#2 and #4) and to arrange an appropriate transfer for one patient (#3) of 30 Emergency Department (ED) 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 EMC) BJC East,” published 10/01/24, showed: - An EMC means a medical condition manifesting itself by acute (sudden onset) symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to any bodily functions or serious dysfunction of any bodily organ or part. - Any individual requesting emergency care or treatment must receive an appropriate MSE, beyond medical triage (process of determining the priority of a patient’s treatment based on the severity of their condition), by qualified medical personnel, including ancillary services routinely available and within the hospital’s capacity and capability, to determine if an EMC exists. All requests for examination or treatment must be honored. - If an EMC is determined to exist, the hospital must provide either further examination or treatment to stabilize the EMC within its capacity or transfer the individual to an appropriate medical facility. - No patient will be discharged or transferred without a MSE.”

“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: 49404 Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#2 and #4) of 30 Emergency Department (ED). This failed practice had the potential to cause harm to all patients who presented to the ED 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 EMC) BJC East,” published 10/01/24, showed: - An EMC means a medical condition manifesting itself by acute (sudden onset) symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to any bodily functions or serious dysfunction of any bodily organ or part. - When an individual comes to the ED and requests emergency care or treatment the hospital must provide an appropriate MSE, beyond medical triage (process of determining the priority of a patient’s treatment based on the severity of their condition), by qualified medical personnel. - The MSE must be within the hospital’s capacity and capability and include ancillary services routinely available to determine if an EMC exists. - The hospital must honor all requests for examination or treatment. - The hospital must utilize the routinely available ancillary services to conduct the medical screening examination. - No patient will be discharged or transferred without a medical screening examination. Review of Patient #4’s medical record dated 07/20/25, showed: - He was a 23-year-old with no past medical history. - On 047/20/25 at 5:54 PM, he presented to the ED with a complaint of a chemical exposure. He stated he “breathed in” a small amount of freon on 07/17/25, and since that time had muscle weakness and body aches. - He had no past medical history. - At 8:00 PM, his Vital signs (VS, measurements of the body’s most basic functions: Blood pressure (BP) normal between 90/60 and 120/80; heartbeats (HR) normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; and body temperature (T) normal 97.8 to 99 degrees) were BP-130/77, HR-87, RR-16 and T-98.5o Fahrenheit (F). His oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) was 100%. - At 6:02 PM, his pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was seven of 10. - At 6:21 PM, a nursing musculoskeletal (bones, muscles, joints, tendons and ligaments which all work together to provide the body with support, protection, and movement) assessment showed he had generalized weakness. - At 6:25 PM, the provider note showed he had fatigue (weakness or tiredness), muscles aches and pains and a headache. The body aches and headache developed a day after the freon exposure. - The exposure was discussed with poison control and there was no concern and stated he was outdoors and did not exhibit signs or symptoms of freon toxicity. - The differential diagnoses included freon inhalation, viral infection and overuse syndrome. - At 6:32 PM, Staff L, Physician, electronically signed the record after Staff S, PA. - At 6:35 PM, he was discharged home with instructions to treat his symptoms with over-the-counter medications and to call poison control if he had concerning symptoms. Review of Patient #4’s Hospital B medical record showed: - On 07/20/25 at 11:41 PM, he presented to the ED with a complaint of generalized body aches since 7/16/25, he reported not being able to pick up a gallon jug or open a car door. He reported no appetite. He had burnt freon his him in the face the same day the symptoms started. - The history and physical note showed he was seen at Parkland Health Center; conservative treatment was recommended, and they did not believe his symptoms were related to freon exposure. - His platelets (cell fragments in the blood that initiate clot formation and stop or prevent bleeding, normal is 150 to 400) were 138. - His creatinine kinase (CK, a blood test that shows if there is damage to your heart, skeletal muscles or brain, normal is 39 to 308) was 1,930. - His C-reactive protein (CRP, a blood test to check for inflammation in the body, normal is less than 5) was 6.6. - His aspartate aminotransferase (AST, an enzyme that is found mostly in the liver, normal is less than 41) was 83. - He was admitted with a diagnosis of mild rhabdomyolysis (serious syndrome due to muscle injury where the muscles break down). During a telephone interview on 09/10/25 at 12:35 PM, Staff L, Physician, stated that she did not care for Patient #4, she did review the chart prior to the interview. She signed off on the medical record because Staff S, PA, asked for her help contacting poison control. She believed the patient had worked out too hard. When asked her professional opinion regarding any additional work up related to the patient’s symptoms not related to his freon exposure, she declined to answer. During an interview on 09/09/25 at 12:00 PM, Staff O, Clinical Excellence Director, stated that Patient #4’s mother filed a grievance (a formal written or verbal complaint related to care or service that cannot be resolved immediately at the bedside) on behalf of her son but she was not on the Health Insurance Portability and Accountability Act (HIPAA, provides privacy standards and protects patients’ medical records against unauthorized access) form for release of information. She alleged that the hospital failed to listen to her son, and he was admitted to Hospital B after he was discharged. The son never returned her call to obtain consent to release information to his mother. The chart review showed Patient #4 was ruled out for dehydration (a condition caused by excessive loss of water from the body) and was not seen at Hospital B until 12 hours after he was discharged. Although requested, Staff S, Physician Assistant (PA, a type of mid-level health care that can serve as a principal healthcare provider), she was not available. Review of Patient #2’s medical record, dated 02/26/25, showed: - At 8:25 PM, he was a 64-year-old who presented to the ED with left side/rib pain from a gastrostomy tube (G-tube, soft, flexible tube inserted through the skin of the abdomen and into the stomach). He appeared to be in moderate discomfort. - No past medical history was recorded. - At 8:43 PM, his vital signs (VS, measurements of the body’s most basic functions: blood pressure (BP) normal between 90/60 and 120/80; heartbeats (HR) normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; and body temperature (T) normal 97.8 to 99 degrees) were BP-166/85, HR-72, RR-18 and T-97.7o Fahrenheit (F). His oxygen saturation (SAO2, measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) was 100%. - At 8:44 PM, his pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was eight of 10. - At 9:07 PM, a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) was within normal limits. - At 9:24 PM, a comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) showed an alkaline phosphatase (an enzyme responsible for bone growth and repair, normal is 40 to 130) was 158 and a creatinine (blood test that shows how the kidney is functioning, normal is 0.8 to 1.3) was 0.59. - At 9:38 PM, an electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed normal sinus rhythm (NSR, rhythm of a healthy heart). - At 9:41 PM, a nursing skin assessment showed the percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person’s abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) insertion site was red and inflamed. - At 9:51 PM, a Troponin T High Sensitivity (a blood test that measure whether or not a person is experiencing a heart attack, normal result is between 0 and 22) was 13. - At 11:10 PM, 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) scan showed the stomach was significantly distended with fluid with a prominent area of narrowing at the duodenal bulb (portion of the small intestine, right after the stomach) with suspicion for a small amount of free air (air or gas is present in a part of the body where it should not be, often indicates a perforated organ). A surgical consultation was recommended. - At 11:17 PM, a phone consult was placed to Hospital B’s access line. - At 11:52 PM, the ED Provider note showed the patient was an inmate at the local prison system and the prison system used Hospital B’s facility for inpatient care. - On 07/27/25 at 12:02 AM, intravenous (IV, in the vein) antibiotics and protonix (medication used to treat too much acid in the stomach) were administered and a chest x-ray showed no evidence of an acute (sudden onset) process. - At 12:07 AM, the ED Provider note showed Staff M, Physician, spoke with the prison’s on-call physician and the on-call physician recommended to transfer the patient to Hospital B as they had contracts with Hospital B. - At 12:34 AM, Hospital B’s Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients) wanted to speak to Hospital B’s ED physician about a possible ED to ED transfer as the patient may have had a perforated viscus (a medical emergency where a hole or tear forms in the wall of a hollow organ in the abdomen). - At 12:37 AM, a lactate test (test that measures level of lactic acid [an acid produced in muscle tissue cells and red blood cells during strenuous exercise], normal level is 0.7-2) was 1.3. - At 1:09 AM, Hospital B’s hospitalist accepted the patient as a direct admission. The EMTALA transfer form showed the reason for transfer was a higher level of specialty services unavailable at Hospital A. - At 4:10 AM, he was discharged. During a telephone interview on 09/09/25 at 2:18 PM, Staff M, Physician, stated that when Patient #2 was determined to have an EMC he contacted the prison system physician and received a request to transfer the patient to Hospital B because Hospital B had a contract with the prison system. When Staff M was questioned as to why the EMTALA transfer form showed the reason for transfer was to higher level of specialty services unavailable at the facility, he responded, “that was a mistake.” He clicked the wrong box; he should have clicked transfer per request. Surveyor: Gray, Emily 48359”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to arrange an appropriate transfer for one patient (#3) out of 30 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented seeking care in the ED. 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): BJC EAST,” published 10/01/24, showed: - When an individual is determined to have an emergency medical condition (EMC), the hospital will provide necessary examination and treatment to stabilize the patient within the hospital’s capabilities and capacity; and follow established protocols for appropriate transfer of the patient to another medical facility if indicated or if requested by the patient. - If an EMC is determined to exist, the hospital must provide either further examination or treatment to stabilize the EMC within its capacity or transfer the individual to an appropriate medical facility. - An appropriate transfer is a transfer in which the transferring hospital provided medical treatment within its capacity that minimizes the risks to the individual’s health and one in which the receiving facility has available space and qualified personnel for the treatment of the individual. Review of the hospital’s document titled, “No Doc Cardiology July 2025,” showed Staff Q, Physician, was on-call 07/24/25 through 07/27/25. Review of the hospital’s document titled, “General Surgery July 2025,” showed Staff R, Physician, was on-call 07/24/25 through 07/27/25. Review of Patient #3’s medical record, dated 07/24/25, showed: - At 6:15 PM, a 73-year-old male presented to the ED with chest pain that began at approximately 1:30 PM, while he was sitting in a chair. He reported the pain started very sharp and had eased up some; he denied nausea. - His past medical history included coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing) and high blood pressure. - His past surgical history included four cardiac stent placements (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) over 10 years ago. - At 6:21 PM, his vital signs (VS, measurements of the body’s most basic functions) were within normal limits, except for an elevated blood pressure (BP, normal between 90/60 and 120/80) of 165/82. His pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was four of 10. - At 6:24 PM, his electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed sinus rhythm (SR, rhythm of a healthy heart) with a first-degree atrioventricular (AV) block (a mild type of heart arrhythmia). - At 6:29 PM, the nursing cardiac assessment showed within defined limits. Symptoms included chest pressure (pain across both sides of his lower chest). He rated the pressure at a four of 10. - At 6:34 PM, the nursing gastrointestinal assessment showed within defined limits. His symptoms included nausea. - At 6:57 PM, his Troponin T High Sensitivity (a blood test that measure whether or not a person is experiencing a heart attack, normal result is between 0 and 22) was 19. - At 7:13 PM, the ED provider documentation indicated they were waiting to talk to the Patient #3’s cardiologist (a physician that specializes in the care of your heart and blood vessels). At that time, based on the fact that he had not had a cardiac catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions) for quite some time, his chest pain and his risk factors, the plan for his disposition was to be to the care of his established cardiologist. Hand off was provided to the oncoming physician, advising that they were waiting for a return call from the patient’s cardiologist. - At 7:19 PM, his alkaline phosphatase (an enzyme responsible for bone growth and repair, normal is 40 to 130) was elevated, at 158. - At 8:47 PM, he reported increased pressure in his right lower chest and rated the pressure at a four of 10, with his pain increasing with palpation (using one’s hands to assess the body). - At 8:51 PM, morphine (an opioid pain medication) was given intravenous push (IVP, to manually administer a dose of medication through a tube into a vein) for pain. - At 8:57 PM, a repeat EKG showed SR with a first-degree AV block. - At 9:01 PM, his Troponin T High Sensitivity two-hour was 15, his Troponin T delta (the change in high-sensitivity troponin T levels between two blood tests. An increase of more than 6 over three to four hours is consistent with acute [sudden onset] heart attack) was -4 and the interpretation was insignificant. - At 9:10 PM and 9:48 PM, his pain scale assessment scores were two of 10. - At 9:12 PM, a phone call consult order was placed with the patient’s cardiologist. There was no documentation of a conversation with the cardiologist. - At 10:25 PM, a phone call consult was placed to Hospital B’s access line. - At 10:46 PM, his Troponin T High Sensitivity four-hour was 14, his Troponin T delta was -5 and the interpretation was equivocal. - At 11:45 PM, Hospital B’s access line responded, Patient #3 was accepted by the Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients). - On 07/25/25 at 1:42 AM, a change in status note showed Patient #3 asked for pain and nausea medication. - At 1:48 AM, he vomited and complained of severe abdominal pain. - At 4:05 AM, his pain scale assessment was nine of 10. - At 4:49 AM, 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) scan of his abdomen and pelvis showed cholecystolithiasis (gallstones [pebble-like pieces of digestive fluid that form within the gallbladder]) that suggested an acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the bile duct [tiny canals that connect some of the organs in your digestive system]) and recommended a gallbladder ultrasound (a test that uses sound waves to create images of structures within the body) for further evaluation. - At 5:08 AM, an order was placed for a gallbladder ultrasound and nursing report was provided to the Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) team. - At 5:10 AM, Staff L documented EMS was there to pick up the patient for transport. The plan was to update the admission team regarding the CT findings and the need for an ultrasound to confirm or rule out acute cholecystitis. - At 5:16 AM, he was discharged. Review of Patient #3’s Hospital B medical record, dated 07/25/25, showed: - At 6:19 AM, he arrived as an elective admission transferred from Hospital A. - At 7:55 AM, the history and physical showed he presented in transfer from Hospital A ostensibly for a cardiology evaluation despite the fact that the originating facility had interventional cardiology. He reported acute onset right upper quadrant abdominal pain which was worse with palpation. - His assessment/plan included a workup for acute cholecystitis to include an ultrasound and general surgery consult. - There was no suspicion for an acute coronary syndrome (ACS, any condition brought on by a sudden reduction or blockage of blood flow to the heart) or angina (chest pain caused by low blood flow to the heart). - At 8:48 AM, a cardiology documentation showed Patient #3 was transferred due to supposed chest pain. The patient stated that palpation to his right upper abdominal quadrant caused pain, it was the same pain he experienced at Hospital A, it was different than any time he had “heart problems.” He had no cardiac contraindications to surgery. He was to follow up with cardiology as an outpatient. - At 1:28 PM, an operative report showed he had a cholecystectomy (surgical removal of the gallbladder; a small organ that stores liquid called bile and helps your body break down food). - On 07/26/25 at 11:30 AM, he was discharged home. During an interview on 09/09/25 at 2:43 PM, Staff N, Physician, stated that Patient #3 presented with “severe chest pain” and had not had a cardiac catheterization in 10 years. His work up looked “okay, at the time.” A normal EKG and troponin did not mean the chest pain was not heart related. A cardiologist may have chosen to perform a cardiac catheterization because of the patient’s chest pain and history. She attempted to contact the patient’s cardiologist but never spoke to him/her. She usually documented a formal consult in the medical record. The goal would be to document the conversation with the consulting physician. When she relinquished care to the on-coming ED provider Patient #3’s disposition was pending since she had not spoken to the cardiologist. The cardiologist needed to determine if Patient #3 required transfer to Hospital B. Patient #3 did not present to the ED with abdominal pain and had no abdominal pain while she cared for him. When questioned for her professional opinion if a continued work up for the abdominal pain could have been considered, she replied she did not want to give an opinion because she was not there. During a telephone interview on 09/09/25 at 1:45 PM, Staff L, Physician, stated that she did not recall Patient #3 and she did not have access to his medical record. She believed he was being transferred because of his cardiology needs to his cardiologist at Hospital B. The transfer process was in progress prior to her assumption of his care. She did not recall speaking to Patient #3’s cardiologist or that the patient had requested a transfer to Hospital B. The CT scan results did not indicate an emergency. His gallbladder could have been evaluated as an outpatient. If the situation was emergent, he could have been evaluated by a surgeon at Hospital A. During an interview on 09/09/25 at 2:03 PM, Staff P, Risk Manager, stated that the cardiac catheterization laboratory was available from 6:30 AM to 3:00 PM.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to inform a patient ’ s representative in advance of providing or discontinuing care for two confused discharged patients (#5 and #14) of three confused discharged patients reviewed (A-0117) and failed to complete temperature checks for the patient nutrition rooms refrigerators and freezers (A-0144). These failures had the potential to affect the quality of care and safety of all patients. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient ’ s Rights. Please refer to A-0117 and A-0144”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to inform a patient’s representative in advance of providing or discontinuing care for two confused discharged patients (#5 and #14) of three confused discharged patients reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s undated policy titled, “Informed Consent,” showed: - Prior to the start of the informed consent process, a provider should understand if the patient has the capacity to make healthcare decisions. Patients are presumed to have decision making capacity if the following four criteria are present, the ability to understand relevant information, to appreciate consequences, are able to reason about treatment options, and are able to make or communicate a choice. - Adults without decision making capacity may not make their own decisions and will require someone else to make decisions on their behalf. - If the patient has a designated surrogate decision-maker prior to their lack of decision-making capacity a legally appointed guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) or an agent appointed under a valid Healthcare Power of Attorney (POA, someone legally designated to make decisions about a patient’s healthcare options, who is not able to make decisions on their own) Document should make decisions for the patient. - If the patient did not designate a surrogate decision-maker prior to losing decision making capacity, the next of kin or others may assist with decision-making. Review of the hospital’s undated policy titled, “Patient Discharge Education,” showed: - At discharge, the nursing staff should review the prepared instructions with the patient or caregiver and verify that they understand the instructions. - The patient/family or caregiver should sign the discharge paperwork. A written or electronic signature is acceptable. - The paper copy can be scanned into the electronic record. Review of Patient #5’s medical record showed: - On 04/10/25 at 3:05 AM, Patient #5 presented to the Emergency Department (ED) via an ambulance from a locked memory care nursing home with aggressive behavior. - His past medical history included stroke, hallucinations (seeing or hearing things which are not there), psychosis (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature), schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly), dementia (a loss of thinking abilities and memory) and cognitive communicative deficit (a term used to describe a weakness in a person’s communication abilities). - Patient #5’s spouse was listed as his next of kin. - At 3:06 AM, he reported that he was brought to the ED because “the firefighter was trying to get my firearm away from me and they were making me ache.” - At 3:13 AM, the nursing neurological (neuro, relating to or affecting the nervous system) assessment indicated that he was oriented to person, which was his baseline, but was forgetful. - His Glasgow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) assessment showed his best verbal response was confused. - His learning barrier was mental impairment. - At 3:15 AM, his provider physical examination indicated he was oriented to being at the hospital but not to the date. He followed simple commands and answered questions appropriately, although not accurately. - At 7:36 AM, his mental health examination indicated he had poor insight and judgement. His presenting problem was “we lost our accountant for this position. It was terrible. She went to bed and didn’t wake up the next morning.” He reported that “he flew in from Vegas last night and the reason he was in the hospital was due to him losing his accountant.” - At 9:20 AM, the consent and authorization for treatment was signed “patient unable to sign due to condition. Verbal consent from patient.” The consent was signed six hours and 14 minutes after his treatment was initiated. - At 12:42 PM, he was discharged in stable condition. - Discharge instructions and follow-up care were reviewed. - Guardian contact was documented as “not required.” - His discharge paperwork did not have a signature, and no next of kin notice regarding arrival, treatment or discharge was documented. During an interview on 05/13/25 at 2:27 PM, Staff Q, Registration Manager, stated that the clinical team was responsible for notifying the registration staff if a patient was confused. That would alert the registrar to contact the patient’s representative for consent to treat. After reviewing Patient #5’s medical record, he stated that the registrar did not follow the hospital’s process. He acknowledged that it appeared that the consent to treatment was signed by a confused patient. The patient’s representative should have been contacted. He stated that common sense should dictated that a confused patient could not consent to hospital treatment. He believed there was an opportunity for staff education. During a telephone interview on 05/13/25 at 11:25 AM, Staff M, RN, stated that she did not recall caring for patient #5. A confused patient was not able to consent to treatment or discharge. The patient’s representative should have been contacted. Her practice was to contact the patient’s representative herself in order to obtain the consent to treat. During an interview on 05/13/25 at 9:48 AM, Staff I, RN, stated that she discharged Patient #5. She did not notify Patient #5’s spouse of his discharge plan. That was an oversight, the nursing home paperwork did not indicate the patient had a guardian. She failed to contact the next of kin for a confused patient prior to discharge. Review of Patient #14’s medical record showed: - On 11/19/24 at 7:34 PM, Patient #14 presented to the ED via an ambulance from a locked memory care nursing home with aggressive behavior. - His past medical history included dementia. - Patient #14’s daughter was listed as next of kin. - Patient #14’s nursing home documentation indicated the patient’s daughter was his guardian. - At 7:44 PM, his presenting complaint was aggressive outburst. He resided on a dementia floor and became agitated with staff members. - At 7:48 PM, the nursing documentation indicated he was able to follow simple commands, but was forgetful. - At 7:48 PM, his GCS best verbal response was confused. - On 11/20/24 at 12:56 AM, Patient #14 attempted to elope (when a patient makes an intentional, unauthorized departure from a medical facility) and stated he wanted to talk to the highway patrol because he believed he had been kidnapped. - At 7:45 AM, his neuro exam indicated he was oriented to person and forgetful. - At 10:53 AM, his mental health examination indicated that he stated that he probably tried to get some pain medicine because he had it 20 minutes before that and then they called the police. There was a gang in the school down there, he did not want to play for them, and they were making it rough on him. He stated he lived three weeks in the past. - At 11:47 AM, Patient #14 was discharged in stable condition. Discharge instructions and follow up care was provided via the discharge summary to the nursing home. - There was no signed consent or authorization to treat. - The discharge paperwork did not have a signature, and no guardian was notified of discharge. During an interview on 05/13/25 at 1:33 PM, Staff O, RN, stated that she typically contacted a confused patient’s next of kin prior to discharge. She would document her communication with the patient’s representative in the patient’s medical record. She was aware the next of kin must be notified prior to discharge and she agreed there was no documentation of that notice for Patient #14. During an interview on 05/13/25 at 3:47 PM, Staff K, Chief Nursing Officer (CNO), stated that she expected if a patient was not alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation) and/or had a neurological deficit a patient’s representative was to be contacted for consent and that representative contact should be documented in the medical record. The patient’s representative should also be contacted prior to discharge. The hospital’s failure to contact Patient #5’s and Patient #14’s representatives did not meet her expectations. She believed the hospital had an opportunity to improve representative awareness of patient arrivals, treatment and discharge from the hospital.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to complete temperature checks for the patient nutrition room refrigerators and freezers. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s undated policy titled, “Cold Storage Temperatures: Food and Nutrition,” directed staff to place a new temperature log form on the clipboard monthly and to record the temperature of each storage unit every morning at opening and every evening at closing. Review of the hospital’s documents titled, “Temperature Log Food Refrigerators,” dated 05/2025, showed: - The refrigerator temperature range for food was 34 to 41 degrees Fahrenheit (F). - If the temperature was out of range staff were to increase or decrease the temperature. If the temperature was too warm, check for food spoilage. Ensure the appliance is securely plugged into an electric outlet and notify Facilities Management if unable to correct the temperature. Relocate food to another refrigerator. - No freezer temperatures were recorded 23 of 23 shifts in the Intensive Care Unit (ICU, a unit where critically ill patients are cared for), Telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) Unit, Medical Surgical 100 Unit, Medical Surgical 200 Unit, Obstetrical (relating to childbirth and the processes associated with it) Unit, Emergency Department (ED) zone one, and ED black zone two. - No refrigerator temperatures were recorded 22 of 23 shifts in the Telemetry Unit, Medical Surgical 100 Unit and Medical Surgical 200 Unit. - No refrigerator temperatures were recorded for 11 of 23 shifts in the ICU, ED zone one, ED white zone two and ED black zone two. - On 05/05/25, The ICU refrigerator temperature was 42 F, no action was taken. - On 05/12/25, the Medical-Surgical 200 Unit refrigerator temperature was 28 F, the Medical-Surgical Unit 100 was 43 F and the Telemetry Unit was 42 F; no actions were taken. Observation on 05/12/25 at 10:15 AM, in the Medical-Surgical Unit 100, showed no refrigerator/freezer temperature logs for the patient nutrition room refrigerator and freezer. Observation on 05/12/25 at 10:20 AM, in the Medical-Surgical Unit 200, showed no refrigerator/freezer temperature logs for the patient nutrition room refrigerator and freezer. During an interview on 05/12/25 at 10:05 AM, Patient #3 stated that she was served sour milk that morning. During an interview on 05/13/25 at 3:47 PM, Staff K, Chief Nursing Officer (CNO), stated that she expected staff to follow the hospital’s policies and procedures. She was not aware the policy required refrigerator/freezer temperature assessments twice each day. She expected staff to intervene when the temperatures were out of range. During an interview on 05/12/25 at 9:30 AM, Staff B, Nurse Manager, stated that the temperature checks was a new process for the staff. She agreed there were no temperature logs in the medical-surgical and telemetry units for 05/2025.”

“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: 48359 Based on interview, record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#3 and #21) of 34 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),” dated 10/01/24, showed: - Barnes-Jewish-Christian (BJC) HealthCare is committed to providing patients with emergency medical care that meets or exceeds the requirements of EMTALA. - Individuals who come to the ED and request emergency care or treatment will receive an appropriate MSE beyond medical triage (process of determining the priority of a patient’s treatment based on the severity of their condition) provided by qualified medical personnel. - The MSE must be within the hospital’s capacity and capability and include ancillary services routinely available to determine if an EMC exists. - The hospital must utilize the routinely available ancillary services to conduct the MSE. - No patient will be discharged or transferred without a MSE. Review of the hospital’s undated policy titled, “Abuse/Neglect (Child/Disabled/Domestic/Elder/Patient Abuse),” showed: - Abuse is defined as any physical injury, sexual or emotional abuse inflicted on a child other than by accidental means by those responsible for the child’s care, custody and control. - The physical assessment includes indicators of abuse such as multiple bruises at different stages of healing. - If health care workers observe the abuse of a child or suspect a child has been abused, they are to immediately notify the child’s primary physician, social work and the nursing supervisor. - When the child exhibits any visible signs of abuse, the nurse and/or social worker shall inform the physician of the need to document with photographs of the injury. - The social worker shall complete the psychosocial assessment, including assessment of physical indicators and history of abuse. The assessment shall be documented in the medical record. - Interview the child privately in a quiet room without interruptions. Obtain the history from the parent/guardian outside the presence of the child. Before screening for abuse, it is essential to create an environment of safety and privacy. - Document assessment, findings and actions taken in the medical record. - A DFS hotline report must be made if abuse is suspected following the evaluation. - Possible characteristics of the abuser include mental illness. Review of the hospital’s undated policy titled, “Parkland Health Center-Assessment/Reassessment of the ED Patient,” showed the registered nurse (RN) will perform an assessment including the patient’s vital signs (VS, measurements of the body’s most basic functions, blood pressure (BP) normal between 90/60 and 120/80; pulse/heartbeats (HR) normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; body temperature (T) normal 97.8 to 99 degrees and oxygen saturation (SAO2) measure of how much oxygen is in blood. A normal is between 95% and 100) including a pain assessment. Routine reassessment will occur throughout the patient’s emergency visit. Review of the hospital’s policy titled, “Pain: Acute Pain Assessment and Management,” dated 02/26/24, showed a pain score is required with routine VS using a pain scale appropriate to the patient’s age, level of understanding and cultural background as determined by the patient and/or licensed care provider. The nurse is responsible for a pain assessment to determine appropriate interventions based upon the patient’s reported pain score.”

“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: 48359 Based on observation, interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#3 and #21) of 34 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),” dated 10/01/24, showed: - Barnes-Jewish-Christian (BJC) HealthCare is committed to providing patients with emergency medical care that meets or exceeds the requirements of EMTALA. - Individuals who come to the ED and request emergency care or treatment will receive an appropriate MSE beyond medical triage (process of determining the priority of a patient’s treatment based on the severity of their condition) provided by qualified medical personnel. - The MSE must be within the hospital’s capacity and capability and include ancillary services routinely available to determine if an EMC exists. - The hospital must utilize the routinely available ancillary services to conduct the MSE. - No patient will be discharged or transferred without a MSE. Review of the hospital’s undated policy titled, “Parkland Health Center-Assessment/Reassessment of the ED Patient,” showed the registered nurse (RN) will perform an assessment including the patient’s vital signs (VS, measurements of the body’s most basic functions) including a pain assessment. Routine reassessment will occur throughout the patient’s emergency visit. Record review of Patient #3 ‘s medical record showed: - On 01/02/25 at 12:10 AM, he was a nine-year-old who presented to the ED with a complaint of vomiting. - His past medical history included intussusception (a life-threatening condition that occurs when part of the intestine folds into another part, blocking food and blood flow), oppositional defiant disorder (ODD, a disorder marked by defiant and disobedient behavior to authority figures), attention deficit/hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors) and constipation. - His mother had a psychiatric (relating to mental illness) history of personality disorder (a type of mental disorder in which a person has a rigid and unhealthy pattern of thinking, functioning and behaving). His father had a psychiatric history of bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows). - At 12:30 AM, his VS were blood pressure (BP) 108/73, heart rate (HR) 85, respiratory rate (RR) 18 and temperature (T) 97.2. There was no assessment of his current pain level, only a stated pain goal of seven. - At 12:31 AM, an abuse assessment showed a denied past or current harmful physical or emotional relationship. A denial of someone making him afraid or unsafe. He had a safe place to go at discharge. There was no documentation of who answered the questions or who was present in the room during questioning. - At 12:34 AM, orders were placed for a urinalysis (UA, a laboratory examination of a person’s urine), a streptococcal (a bacteria) throat swab, a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) and a comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions). - At 1:04 AM, the streptococcal swab was negative. - At 1:42 AM, he played on an electronic tablet, rolled around on a stretcher, laughed and asked for chips. He reported a bowel movement the previous day that was like “rabbit turds,” and vomited five times since 9:30 PM. He showed no visible distress or discomfort and the nurse planned to wait for the provider’s evaluation before collecting the ordered laboratory studies. - There was no nursing skin assessment. - At 2:25 AM, his review of symptoms showed abdominal pain, constipation, nausea and vomiting. His skin assessment was negative for rash and wound. He was visibly anxious and argumentative. - At 3:02 AM, he was provided ice chips by the physician and instructed to “consume slowly.” - At 5:07 AM, a kidney, ureter, and bladder x-ray (KUB; assesses the structures of the urinary and/or gastrointestinal system) showed an increased stool burden (the amount of stool in the colon). - At 5:00 AM, his vital signs were HR 82 and SPO2 100%. No reassessment of his BP, RR or T was performed. - At 5:12 AM, he was discharged with a diagnosis of constipation, nausea and vomiting with instructions to take a laxative (a medication that treats constipation) daily for three days and then as needed to achieve a soft stool every day and to return to the ED with worsening abdominal pain, uncontrolled vomiting or fever. - The CBC, CMP and UA were not performed which is concerning in the context of abdominal pain, nausea and vomiting in that the presence of other Emergency Medical Conditions were not sufficiently ruled out. During a telephone interview on 01/14/25 at 12:00 PM and 01/15/25 at 3:28 PM, Staff G, Physician, stated that he had a vague recollection of Patient #3. He did not recall a facial injury. Patient #3 was resistant to blood draws and had a benign assessment. A KUB is “never enough” to diagnose constipation. The KUB determined Patient #3 did not have a “surgical” abdomen. Patient #3 was discharged home and told to come back if his condition worsened. He expected documentation of the oral challenge tolerance. He expected laboratory study orders to be discontinued when the decision was made to not complete the orders. During an interview on 01/16/25 at 1:13 PM, Staff B, Chief Nursing Officer (CNO), stated that she expected documentation of an oral challenge tolerance. She typically saw an oral challenge begin with ice chips and then advance as tolerated. She expected documentation of why the ordered laboratory studies were not completed. She expected the orders to be discontinued. During an interview on 01/14/25 at 4:10 PM and 01/16/25 at 12:56 PM, Staff X, ED Manager, stated that she expected documentation of a skin assessment with a visible injury. Upon review of Patient #3’s medical record she stated that the injury “looked pretty visible.” She expected documentation of an oral challenge tolerance. She expected a thorough pain assessment in triage and prior to discharge. She expected staff to follow the abuse policy if abuse was suspected. An event report was not always completed when child abuse was observed. The hospital had a learning opportunity with the policy for abuse. If a provider decided not to perform previously ordered laboratory studies, she expected the orders were discontinued. She expected documentation of why the laboratory studies were not performed. She was not notified of Patient #3’s DFS hotline. Typically, she was only notified of a DFS hotline if there was something “unusual.” During a telephone interview on 01/15/25 at 9:22 AM and 01/16/25 at 10:15 AM, Staff J, RN, stated that she did not see the facial injury during Patient #3’s first ED visit. She stated that Patient #3 appeared to be in pain. She did not know why she documented a stated pain goal of seven. He did not rate his pain with a number. He intermittently grimaced and held himself with the pain. The pain appeared to be “spasmodic.” She ordered laboratory studies per protocol because she could not in “good conscious” dismiss his pain. She reported her assessment to his primary nurse. She believed the laboratory studies were necessary. Patient #3 had behavioral issues and she was concerned his behavior could have been a deterrent to his care. She assessed “some level of dysfunction” between Patient #3 and his mother. She did not review the chart for a history of abuse “she was too busy.” She felt Patient #3’s mother may have been “battered” herself, she did not want to make Patient #3 “mad.” She believed the family was involved with social work because the mother seemed engaged, passive and structured when managing Patient #3. She performed the abuse assessment with the patient and his mother in the room. Both answered the abuse questions. During a telephone interview on 01/15/25 at 11:40 AM, Staff K, RN, stated that she did not remember the report she received from Staff J, RN. If a child did not show distress, laboratory studies ordered per protocol were held until the patient was evaluated by the provider. She questioned the parent’s regarding how the child was behaving. She did not document “everything that was said.” If a provider decided the laboratory studies were not necessary, the orders were discontinued. She did not recall Patient #3’s facial injury. “In a perfect world,” she expected documentation of an oral challenge tolerance if she performed the assessment. If she was “too busy,” she may not document something not “notable.” She may not document 100 percent of the time if there were other critical issues. During a telephone interview on 01/15/24 at 3:00 PM, Staff M, RN, stated that Patient #3’s injury was easily visible and appeared red, yellow and green. She was confident Patient #3’s injury did not occur after his discharge that morning and was present during his previous visit. Patient #3’s mother pointed out the older bruising. She completed a full assessment after she identified the facial injury. She expected documentation of an oral challenge tolerance. She stated that she would have obtained the laboratory studies based on the triage nurse’s assessment. The provider stated that Patient #3 appeared lethargic (weak, sluggish). Patient #3 was transferred to Hospital B because the antinausea medication and oral challenge failed. It was hard for her to say if Patient #3 was fully evaluated during his prior ED visit. If a patient asked for food with abdominal pain, she needed to see him/her tolerate the food to determine if his/her condition improved. “Lots of people ask for food with abdominal pain, they think the pain is from hunger.” Review of Patient #21’s medical record, showed: - On 12/03/24 at 3:29 PM, she was an 85-year-old who presented to the ED with confusion and weakness after a recent fall and suspicion for a seizure disorder (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness). - Her past medical history included chronic kidney disease (CKD, ongoing, gradual loss of kidney function), dizziness, bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and schizo-affective disorder (mental health disorder where speech and thought are disorganized, and a person may find it hard to function socially and at work and may experience hearing voices that are not real). - At 3:48 PM, her complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) showed her white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 3.8-9.9) was 21.4. - At 3:53 PM, the physician reviewed her CBC and comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) from 08/23/23 that showed her WBC count was 10.10 and creatinine (blood test that shows how the kidney is functioning, normal is 0.6 to 1.1) was 1.03. - At 4:38 PM, her urinalysis (UA, a laboratory examination of a person’s urine) was within normal limits. - At 5:11 PM, 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 chronic (long term, on-going) appearing small vessel ischemic (restriction in blood supply to tissues, causing a shortage of oxygen needed to keep tissue alive) changes. - At 6:06 PM, her CMP showed her creatinine was 1.66. - At 6:31 PM, she was discharged with a diagnosis of tremor and generalized weakness. She was provided instructions to take pain medications, drink plenty of fluids to stay hydrated, take her medications as prescribed, return to the ED for any concerning or worsening symptoms and to follow up with the Primary Care Physician (PCP) in three to four days if she showed no signs of improvement. - In the context of an elevated WBC, all sources of an infection had not been ruled out. - An appropriate MSE was not conducted as evidenced by no chest x-ray or electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) ordered. - The provider failed to consider leukocytosis or the prior fall. The CBC, CMP and UA were not performed which is concerning in the context of abdominal pain, nausea and vomiting in that the presence of other Emergency Medical Conditions were not sufficiently ruled out. Review of Patient #21’s Hospital C medical record showed: - On 12/04/24 at 1:24 PM, she presented to the ED with dizziness and increased altered mental status (mental functioning ranging from slight confusion to coma). - At 3:50 PM, her troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.01) was 107 and proBNP (a protein produced by the heart that acts as a signal indicating when the heart is working too hard, often due to heart failure, normal is 0-450), was 8,354. - At 3:59 PM, she was admitted to inpatient with encephalopathy (damage or disease that affects the brain), pneumonia (infection in the lungs), heart failure (a chronic condition in which the heart cannot pump or fill adequately), parkinsonism (a term that refers to brain conditions that cause slowed movements, rigidity [stiffness] and tremors), dementia (a loss of thinking abilities and memory), convulsions (sudden, violent, irregular movement of a limb or of the body), CKD, bipolar disorder, schizoaffective disorder, early onset Alzheimer’s disease (a chronic brain disorder characterized by gradual loss of memory, decline in intellectual ability and deterioration in personality) and disorders of the kidney and ureter. - At 4:00 PM, a chest x-ray showed left lower lung lobe atelectasis (collapse of part or all of a lung) and less likely a lung contusion (an injury that doesn’t break the skin but results in some discoloration). During an interview on 01/14/25 at 12:00 PM and 01/15/25 at 2:37 PM, Staff U, Physician, stated that a “normal workup” for a patient with a fall, weakness and/or confusion was to evaluate the patient for heart problems, stroke and/or urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). A head CT, CBC, CMP and UA would be ordered, and current medications reviewed. The patient would be evaluated for alcohol and drug use and an examined for bruising, pain and/or injury. Patient #21’s elevated WBCs was an “outlier” and no further investigation was completed. Patient #21’s current and past CBC and CMP lab results were reviewed for trends and if there was a concern she would have put it in her note. Her CMP reflected CKD; therefore, a nephrology consult was not ordered. Additional imaging for Patient #21 was not ordered. During an interview on 01/16/25 at 3:35 PM, Staff O, Physician, stated that he expected a radiology (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) work up to locate the cause of the elevated WBCs and the source of the infection. He expected a consult with nephrology for a patient with history of CKD who presented with abnormal labs. During an interview on 01/16/25 at 1:14 PM, Staff B, CNO, stated that she expected a further work up, including a chest x-ray and cultures (a test to identify bacteria that may cause an infection) to rule out an infection with elevated WBCs. “It was a missed opportunity.” 50496”