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Based on review of medical records, review of Medical Staff Bylaws, review of policies and procedures, staff interviews and review of video recording dated 12/23/2021, it was determined that the facility failed to provide an appropriate medical screening examination within its capability and capacity for one of 20 sampled patients (P) #1 when P#1 presented to the Emergency Department (ED) on 12/23/2021 with a complaint of a headache. Specifically, the complainant alleged the facility denied medical treatment after an altercation with another patient and P#1 was asked to leave the ED.

Findings were:

Cross refer to A-2406, as it relates to the facility's failure to provide P#1 with an appropriate medical screening examination.

Based on review of medical records, review of Medical Staff Bylaws, review of policy and procedures, staff interviews, and review of video recording dated 12/23/2021, it was determined that the facility failed to provide an appropriate and ongoing medical screening exam within the capabilities of the facility for one of 20 patients (Patient #1) when Patient (P) #1 presented to the Emergency Department (ED) on 12/23/2021 with a complaint of a headache. Specifically, the complainant alleged the facility denied medical treatment after an altercation with another patient and P#1 was asked to leave the ED.

Findings included:

A review of P#1's medical record revealed that P#1 presented to the facility's Emergency Department (ED) on 12/23/21 at 5:07 p.m. with a chief complaint of a headache. A continued review of the ED Triage Form completed by Registered Nurse (RN) CC revealed that P#1 was triaged at 5:40 p.m. P#1 complained of neck pain that radiated to her head. Additionally, P#1 had complained of pressure in her lower back. It was noted that P#1 had a history of disc problems in her lower back, and P#1 described the pain she was experiencing as the same type of pain. A continued review revealed that P#1 was out of medication. P#1 was given an acuity level of four (Stable- patient presented with a condition that had a low potential for deterioration or complications). A review of a Pain Assessment completed by Licensed Practical Nurse (LPN) EE revealed that P#1's pain was reassessed at 6:06 p.m. and was unchanged. A further review revealed a nurse's note documented by Registered Nurse (RN) DD at 6:40 p.m. that noted that P#1 was yelling and threatening other patients in the Preliminary Results area of the ED. Security was called, and P#1 was advised that she could leave. P#1 chose to leave and walked out of the ED with no signs or symptoms of distress. A further review of P#1's medical record did not reveal a medical screening exam for P#1 before leaving the ED. P#1's discharge disposition was documented as left without being seen at 6:54 p.m.

A review of video recordings from the ED on 12/23/21 took place on 1/11/22 at 12:00 p.m. with Security Manager (SM) II. Video recording titled ER Registration 20211223_184858 revealed a view of the ED registration area. P#1 and male visitor entered area from double doors on the right side. P#1 walked through, followed by male visitor, then followed by SS GG. P#1 walked through door to exit, and male visitor appeared to make an obscene gesture with his hand as he walks through the first set of doors. SS GG followed behind. Video recording titled ER Entrance Interior 20211223_184911 revealed a view of the breezeway of the main ED entrance. P#1 was observed walking through to the exterior door followed by male visitor and SS GG. As male visitor exits exterior door, he turns back toward SS GG, placed a beverage bottle on the ground and took a stance toward SS GG. P#1 was observed reaching for visitors left arm. SS GG stepped back then holds visitors right arm and appeared to guide him out of the exterior door. P#1 observed picking up beverage, turning, and walking out of view to the left. SS GG observed stepping just outside the exterior door and standing.

A review of the facility's "Medical Staff Bylaws," last revised 08/2019, revealed in:

I. Emergency Department Services

1. All patients that presented to the ED had a medical screening examination performed by a physician and/or physician extender or other individual authorized by the Medical Staff Bylaws Rules and Regulations or other Board approved document. The exam included but was not limited to a history of the patient's current complaint and the use of ancillary services routinely available to determine whether an emergency medical condition existed as delineated in the ED Medical Screening Procedure #21.071:1.

A review of the facility's policy number GOR.DEP.1267, titled 'Triage,' last reviewed 5/10/17, revealed that triage involved a rapid, directed patient screening to determine life or limb-threatening conditions and treatment priorities. Triage was performed by registered nurse or other qualified emergency personnel using the Emergency Severity Index (ESI). ED patients had a chief complaint and triage assessment with ESI acuity scale as intake assessment.

Acuity level definitions and Assignment:
1. ESI Triage Level One: Critical- patient presented with the need for immediate life-saving interventions. Patient immediately placed in the patient care area for definitive assessment and intervention. The physician and charge nurse were notified immediately. Examples included: cardiac arrest, shock, airway/breathing compromise, gunshot wounds, major burns, near drowning.
2. ESI Triage Level Two: Unstable- patient presented with a condition posing threat to life, limb, or function and required rapid medical intervention. Patient placed in the first available patient care bed. Triage nurse notified the charge nurse and documented notification on the triage assessment. Examples included: overdose (conscious), CVA, head injury, severe trauma, chest pain, allergic reaction, diabetes.
3. ESI Triage Level Three: Urgent- Patient presented with a condition that could progress to a serious problem requiring emergency intervention. The vital signs may or may not be out of normal range. Condition was anticipated to utilize two or more resources. Examples included: dialysis problem, abdominal pain, signs of infection, vomiting, and diarrhea (less than 2 years), pain score 7/10, acute psychosis, mild or moderate asthma.
4. ESI Triage Level Four: Stable- patient presented with a condition that had a low potential for deterioration or complications. One resource was expected to be used. Vital signs must be taken and meet criteria for designated area of ED. Examples included: depression (w/o SI), minor trauma, chronic back pain, headache, corneal abrasion/FB, vaginal discharge (without pregnancy).
5. ESI Triage Level Five: Routine- patient presented with a condition that may be acute but not urgent; may be part of a chronic problem without evidence of deterioration. No resources were anticipated to be used. Vital signs must meet criteria to be assigned to the designated area. Examples included: minor trauma, sore throat, menses, dressing changes, abdominal pain.

Patients awaiting treatment were advised as to the reason and assurance that they will be attended to as soon as possible.

A review of the facility's policy entitled, "Medical Screening," Policy #GOR.DEP.1248, last reviewed 7/16/21 revealed that a Medical Screening Exam (MSE) would be performed regardless of a person's ability to pay, sex, race, creed, or religious belief. A physician and/or midlevel provider must perform the MSE. The MSE would include but was not limited to the history of the patient's current complaint and any ancillary services routinely available to the emergency department (ED) to determine whether an Emergency Medical Condition (EMC) exists. Once the medical screening was completed and determined that the patient did have an (EMC), the patient would be treated in the ED. If upon completion of the medical screening and the determination was made that that no EMC existed, other options would be offered to the patient that could include referral to their primary care physician, referral to the back-up physician in the event the patient was unassigned, or the patient may be treated in the ED.

A review of the facility's policy entitled "EMTALA," Policy #CW CR 500, last reviewed 11/24/20, revealed that the facility was prohibited from engaging in any actions that would discourage individuals from seeking emergency care. When a patient came to the emergency department (ED), and a request was made on the patient's behalf for examination or treatment of a medical condition, the hospital must provide an appropriate medical screening to determine if an Emergency Medical Condition (EMC) exists. If an EMC does exist, the facility must provide stabilization of the medical condition within the capabilities of the hospital or provide transfer to another facility.

A review of the facility's "2021 Annual Required Education for Associates, Bare Facts" revealed the facility must provide medical screening to any person who presented to the facility requesting a medical evaluation. A medical screening exam was an assessment completed by a qualified professional to determine if the patient had an emergency condition. An emergency condition was a condition that without immediate medical attention could result in serious impairment of a body organ or function. A continued review revealed that associates and medical associates could not make any statement or take any action that would encourage a patient to leave before evaluation of a possible emergency medical condition.

An interview with Registered Nurse (RN) CC took place via teleconference on 1/11/22 at 9:30 a.m. from the conference room. RN CC recalled that she had triaged P#1 on 12/23/21. She recalled that P#1 complained of neck pain and had a history of some type of neck injury. P#1 recalled that P#1 reported that she was out of her pain medication. After triage, RN CC escorted P#1 to the Pending Results (PR) area that was being used as a fast-track area for stable, less acute complaints. RN CC explained that the patient chairs in the PR area were separated by screens for privacy. RN CC stated that sometime later, she heard a female yelling in the PR area. When she arrived in the PR area, she observed P#1 and the patient next to P#1 yelling at each other. A patient care technician was attempting to de-escalate the situation along with a security staff member. RN CC recalled that she did not have further interaction with either patient afterward as P#1 appeared to be calming down. RN CC explained that if a patient expressed a desire to leave prior to a medical screening, staff tried to convince them to wait and be seen by a provider.

An interview with RN DD took place on 1/11/22 at 10:00 a.m. in the conference room. RN DD recalled P#1 and stated that she had been the charge nurse during that shift. RN DD recalled that she responded to the PR area after hearing an overhead page for security. When she arrived, P#1 was yelling at the staff using foul language, demanding that she be given pain medication now. RN DD stated that security was present and attempting to get the patient to calm down. RN DD observed the security staff speaking to P#1 in a calm manner and did not place his hands on P#1 or the adolescent male that accompanied her. RN DD recalled that she explained to P#1 that there would be a wait to be seen, but she (P#1) would need to stop yelling and using foul language; otherwise, she (P#1) was free to leave. RN DD recalled that she did not P#1 that she had to leave or that the ED would not treat her (P#1), but behavior that disturbed other patients would not be tolerated. P#1 yelled toward the staff, 'F@#$ you, I'm gonna sue you all.' P#1 and the accompanying male left the area, walking toward the lobby. P#1 ambulated without problems and did not appear to be in distress. Security followed behind her. After P#1 left the PR area, RN DD spoke to the patient that had been sitting in the chair next to P#1. The patient told RN DD that P#1 had been continually yelling about having to wait when she (patient) asked P#1 to stop yelling. P#1 then started yelling and calling the patient names and threatened her.

A teleconference interview with LPN EE took place on 1/11/22 at 10:30 a.m. from the conference room. LPN EE stated that she was the nurse assigned to take care of patients in the PR area. LPN EE explained that on that day, the PR area was being used for patients that were stable and did not require immediate treatment. She explained that the ED had been extremely busy on 12/23/21, and many patients were waiting to be seen. LPN EE recalled that P#1 had complaints of neck or head pain. A teenage appearing male accompanied P#1, who approached the nurse's station multiple times, asking when P#1 would be seen. LPN EE performed and documented P#1's assessment. LPN EE recalled that she was in a patient room when she heard yelling in the PR area. When she responded to the PR area, LPN EE observed a provider and a security staff member standing by P#1's chair. LPN EE did not see or hear the events that precipitated security being called. LPN EE heard RN DD tell P#1 that it will be a wait before a provider can see you (P#1), but we can't have that type of behavior here in the ED. LPN EE recalled that at that point, P#1 got up and yelled, 'F@#$ Y'all, I'm going to sue Y'all' and proceeded to walk toward the lobby. Security followed behind P#1 and the teenager. LPN EE stated that no one physically touched P#1 or the teenage boy. LPN EE stated that she did not hear anyone telling P#1 that she had to leave or that the facility would not treat her.

An interview with the Emergency Department Director (EDD) AA took place on 1/11/22 at 11:15 a.m. in the conference room. EDD AA explained that he had not been in the ED on 12/23/22 when P#1 was present but was told of the details a few days later. He had not been aware of any staff member putting hands-on P#1 or the teenage boy. EDD AA explained that there was not a form for patients to sign if they (patients) choose to leave prior to being seen by a provider in the ED.

An interview with security staff (SS) HH took place on 1/11/22 at 11:30 a.m. in the conference room. SS HH recalled that he responded to the PR area in response to disruptive patient (P#1). When he arrived, P#1 was yelling and cursing at the patient in the chair next to her. SS HH told P#1 that she would need to lower her voice because she was disturbing other patients. P#1 continued to yell and demanded to be given medication. SS HH recalled that he told P#1 that she would be seen as soon as possible, but she would need to stop disturbing other patients. At this point, SS HH recalled that P#1 got up from the chair and began walking out of the ED. There was a male with her that appeared to be a teenager. SS HH followed behind. SS HH recalled that P#1 and the visitor made obscene hand gestures as they were walking through the lobby. P#1 and the visitor were exiting the exterior door when the male turned, placed his belongings on the ground, and lunged at SS HH. SS HH stated that he grabbed the male's wrist and pushed him back, and P#1 then grabbed SS HH arms HH then pushed P#1 away from him and instructed them to leave the premises. SS HH stepped outside and observed P#1 and the visitor get into a car and leave the property. P#1 and the visitor yelled obscenities as they walked to the car. SS HH recalled that he proceeded back into the ED to speak with the patient that had been sitting next to P#1. The patient told SS HH that P#1 had threatened her with a knife and grabbed her arm.

An interview with Nurse Practitioner (NP) HH took place on 1/11/22 at 2:45 p.m. in the conference room. NP HH recalled that she was speaking with another patient in the PR area when P#1 began yelling and cursing about the wait. NP HH explained to P#1 that she (P#1) would be seen as soon as possible, but currently, she (NP HH) was assessing another patient. NP HH recalled that stepped away for a short time, and when she returned, P#1 and the patient next to P#1 were yelling at each other. Someone called for security, and an officer responded quickly. The patient next to P#1 was moved to another chair. NP HH recalled that security and the charge nurse spoke to P#1, but she did not hear the conversation since she left the area to see another patient. NP HH did not witness P#1 leave. NP HH did not witness a physical altercation by anyone involved.

P#1 was not provided a medical screening exam by a qualified medical person.