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Based on observation, reviews of medical records, policies and procedures, daily activity sheet and staff interviews, the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital ' s emergency department. This includes ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed after the presentation status had changed while still on hospital property for 1 (patient #1) of 26 medical records reviewed. Please refer to findings in Tag A -2406

Based on observation, reviews of medical records, policies and procedures, daily activity sheet and staff interviews, the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital ' s emergency department. This includes ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed after the presentation status had changed while still on hospital property for 1 (patient #1) of 26 medical records reviewed.

Findings:

1. Interview with the complainant on 08/08/2014 at 10:30 AM revealed the patient #1 had gone shopping with her sister and her mother on 07/29/2014 and she complained of headaches and body pain. The patient ' s family believed that something was not right and convinced the patient to go the Emergency Room (ER) for an evaluation. The family drove the patient to the ER. The patient was able to walk from the car to the reception desk. Patient #1 was subsequently admitted to another acute care facility (#3) and was in the Intensive Care Unit on a ventilator having seizures according to the complainant.

2. Patient #1 ' s medical record from Lake City Medical Center was reviewed. Review of the form " Emergency Patient Record " revealed that patient #1 arrived to the Emergency Department and walked to the reception desk and was signed in at 18:30 (6:30 p.m.). Patient #1 was triaged (degree of urgency to illness to decide the order of treatment) by a triage nurse as semi -urgent. The patient ' s vital signs at 18:55 (6:55 p.m.) taken by the triage nurse was listed as: Blood Pressure: 148/75; Pulse: 100; Respirations: 18; temperature: 98.1 Pain level -8 (pain scale 0-10 -0 no pain and 10 being the worst pain). At 18:34 (6:34 p.m.) the patient was taken to a room where she concurrently received a medical screening examination by triage Physician ' s Assistant, (PA). Review of the patient ' s medical record indicated that family was not present during the medical screening examination (MSE) and was not interviewed by either the PA or the triage nurse. Review of the " Emergency Provider Report " (EPR) , dated 7/29/2014 at 1855 (6:55 p.m.), indicated that patient #1 presented with " complaint: right arm pain after drinking juice last night ... the quality of the patient ' s pain was documented as aching, severely moderate and the pain was exacerbated by range of motion. The review of systems sections indicated in part, " Gastrointestinal: diarrhea (one episode yesterday) Musculoskeletal: extremity pain right arm. The PA documented in part, Physical examination: " Extremities: assessment ... patient (pt.) had mild pain with passive and active pronation and supination of right arm. MDM (Medical Decision Making). Prob-non-Trauma-ED course: pt... course-pt... had FROM (Full Range of Motion) of right Fingers/arm/hand /wrist /shoulders w (with)/neuro- vascular exam (examination). " The PA documented that the medical screening examination was normal. The patient was then asked to wait in the ER (emergency Room) waiting room until the admission clerk could talk to them. The medical record also revealed that at 18:58 (6:58 P.M.) the patient walked to the waiting room on her own power and with a normal gait. The medical record revealed a document titled NON-URGENT MSE DETERMINATION that the top section " ER Physician " was signed by the ER physician at 1853 (6:53 p.m.) 7/29/2014 stating that " Medical Screening COMPLETE: immediate medical attention not necessary: no acute symptoms of sufficient severity or a woman in active labor found: no immediate serious impairment or dysfunction or organs is reasonably expected. " The lower section of the form: ER REGISTRAR was signed by the registrar at 1914 (7:14 p.m.) by the registrar and revealed " Patient elects not to continue medical care with this facility and care givers at this time. Patient provided with information related to alternate community medical resources. " Further review of the medical record revealed that the patient was walked back to the ER Registrar desk. The document revealed that the patient physically left the building at 1914 (7:14 p.m.).

3. Review of the Daily Activity Sheet completed by the Security Guard dated 7/29/2014 revealed the following entry at 1940 (7:40 p.m.) " Called to admitting, person will not leave the admitting office- Lake City Police Department (LCPD) called to remove person from admitting office-Person will not talk-sister may cause problems-Police arrived at 1950 (7:50 p.m.) -remove person from admitting office " .


4. Review of the EMS Pre-hospital Care Report Summary dated 07/29/2014 revealed that the patient ' s initial vital signs were BP 189/105, P 130 (normal pulse 60-100) R- 22 and BS 301. Review of the Narrative History Text revealed, " MEDIC 1 DISPATCHED TO LCMC (Lake City Medical Center) FOR A pt.. (Patient #1) IN THE PARKING LOT. UPON ARRIVAL pt.. FOUND IN A WHEELCHAIR. ER STAFF WAS WAITING OUTSIDE WITH PAT (Patient #1). STAFF STATED WAS SEEN FOR SHOULDER PAIN AND DISCHARGED. pt.. THEN COMPLAINED OF WEAKNESS AND WAS SITTING IN THE LOBBY REFUSING TO LEAVE LCMC. HAD LCPD (Police Department) COME AND REMOVE THE PATS. pt. ' S FAMILY WAS ON SCENE AND CALL 911 FOR AN AMBULANCE TO TRANSPORT pt. TO HOSPITAL NAME (ACUTE CARE FACILITY #2). UPON ARRIVAL pt. ALERT TO PAINFUL STIMULI ONLY. pt. SECURED TO STRETCHER AND LOADED INTO UNIT. pt. 42 YOF (Year old female) NOT ALERT. GCS (Glasgow coma scale-assessment for impairment of consciousness level) 9 (2-2-5) AIRWAY PATENT, SHALLOW RESPIRATIONS. LUNGS CLEAR AND EQUAL BILATERALLY. HEE NT (Head Ear Eye Nose and Throat) CLEAR. PUPILS CONSTRICTED, NOT RESPONSIVE. NO JVD (jugular Vein Distention). TRACHEA/MIDLINE. SKIN PINK, HOT, AND DRY. ADB (abdomen) SOFT NON TENDER. +PMS (positive Pulse, Motor Sensation- check legs and hand for pulse, ability to move, and Sensation) IN ALL EXTREMITIES. SINUS TACH ON CARDIAC MONITOR, 12 LEAD UNREMARKABLE. 20 GA (gauge) IV (intravenous) ESTABLISHED IN LEFT HAND",

5. Review of the ER record obtained from Acute care facility #2 dated 07/30/2014 at 0517 (5:17 a.m.) revealed as part of the Physician Documentation " Patient arrives via EMS from Lake City Medical Center ED with unresponsiveness. History per EMS is that the patient was seen in the Lake City Medical Center (LCMC) triage and told she did not have an emergency and was wheeled out to the Ambulance by LCMC staff in a wheelchair and was unresponsive upon their arrival. The report giving 2 mg of IV Narcan (medication that reverses effects of other narcotic medicines) with no response. The family reports the following; patient had N/v/d (nausea/vomiting/diarrhea) yesterday, with headache, pain in the back of neck and upper back radiating to the right shoulder. She continued to have N/V today and family states that she was " not acting right " . They described her (patient#1) as being somewhat unfocused and confused with global generalized weakness. Unknown if patient had a fever or not. Onset of the symptoms/episode became/occurred yesterday, and became worse just prior to arrival. Severity of symptoms: At their worst the symptoms were incapacitating in the emergency department, the symptoms are unchanged. The patient has not experienced similar symptoms in the past. The patient has been recently seen by a physician at Lake City Medical Center earlier today, with similar presenting complaints, was MSE ' d (medically screened) and determined not be non-emergent. " Review of the TRANSFER CERTIFICATION FORM completed by Acute care facility #2 on 07/03/2014 at 0515 (5:15 a.m.) revealed the reason for transfer to Acute care Facility #3 was to treat patient #1 ' s diagnosis of Meningitis.

6. The Discharge Summary from acute care facility #3 was reviewed. Review of the discharge summary dated 8/18/2014 revealed in part, " Secondary Diagnosis: Vasospasm of cerebral artery, Diabetes Mellitus, meningitis due to bacteria, seizure. ...Hospital Course ... 42 year old female ... transferred from Acute Care Facility #2 ...for management of meningitis. The patient underwent LP and CT at Hospital B ...Upon transfer the patient was admitted to the ICU (Intensive Care Unit) and intubated for failure to protect airway. There she was noted to have left sided weakness; demonstrated abnormal perfusion in the right MCA (Mid Cerebral Artery) and PCA (Posterior Cerebral Artery)which was diagnosed as vasospasm secondary to meningitis .... She experienced one seizure that lasted 90 seconds ...she was subsequently started on fosphention (medication used to treat seizures) (per neurology for 3-6 months) ...Discharge instructions: PT. (physical Therapy) OT (Occupational Therapy): Physical/Occupational inpatient rehabilitation
Nursing Home/Rehab: Physical/Occupational rehab. "



7. The facility ' s policy titled " EMTALA- Florida medical Screening Examination and Stabilization Policy " Policy #900.036 effective date 2/20/97 was reviewed. The policy specified in part, " Definitions: Services Capability: means all services offered by the hospital where identification of services offered is evidenced by the appearance of the service in a medical record ... Relieve or Eliminate the Emergency Medical Condition means the provision of care treatment ...consistent with the applicable standard of care, by a physician necessary to either eliminate the emergency medical condition or to eliminate the likelihood that the emergency medical condition will deteriorate or recur without further medical attention within a reasonable period of time ... Procedure: WHEN A MEDICAL SCREENING EXAMINATION IS RQUIRED: An individual MUST receive a MSE within the capabilities of the hospital ' s DED (dedicated Emergency Department) to determine whether or not an EMC exists ....1. the individual comes to the dedicated emergency department of a hospital and a request is made on his or her behalf for examination or treatment for a medical condition, Extent of the MSE (Medical Screening Examination): 2. No difference by location: The MSE performed on hospital property other than a DED must be the same medical screening that the hospital would perform on any individual coming to the hospitals DED with those signs and symptoms, regardless of the individual ' s ability to pay for medical care ...5 Varies by presenting symptoms. The facility is required only to perform such medical screening within the scope of its capabilities as would be appropriate for any individual presenting at the DED in that matter to determine that the individual does have an EMC. A. Depending on the individual ' s presenting symptoms, the MSE may range from a simple process invoilving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures.



8. An interview with the triage PA on 08/08/2014 at 12:30 PM revealed that I work both as the triage PA and the ER PA to help out in the back until the second PA comes in at 12 noon if I am not busy. I determine if the person is to be seen in the emergency room by the physician. Every non-emergency patient is discussed with the physician except for suture removals. The patients do not discuss in triage if they are going to be seen in the ER or not. I make the determination then they go to registration, registration gives them the determination that was made and their options. If the person insists on being seen the charge nurse in the ER gets involved. Continued interview with the PA, around 6:30 PM revealed the triage nurse went to get the patient. The patient did not answer when called. The second triage staff arrived and called for the patient and the patient came back. She did complain of some diarrhea the day before, she was afebrile; she had no neck pain whatsoever. There was nothing abnormal about the patient; her only complaint was that her right arm hurt after drinking juice. She walked into the triage area walking normally. About 15 minutes later the registrar came and told me that this patient had vomited in the registration area I told her to talk to the charge nurse. The charge nurse came to me 10 minutes later and asked me if I would take another look at her which I did. Her ESP ' s (Emergency Screening Protocol) remained non- emergent. She was in registration when she seen again in the presence of the charge nurse. Still her only complaint was that her arm hurt. We did not repeat the vital signs in triage or in the admissions area. She did not have a fever. I do not know who called the police. The PA stated this is where I re-evaluated her. During this interview the PA was observed on the side of the desk where the registrar was seated and the desk separated the PA from the patient. He stated that the patient raised her arm and said that it still hurts. The PA stated that he left to go back to the ER and never saw the patient again. Other than the NON-URGENT MSE DETERMINATION form the medical record did not document any information relating to the care the patient received or any events that occurred during the encounter at the registrar ' s desk or after the patient left the registrar desk. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that an appropriate medical screening examination was completed. This includes ancillary services routinely available to emergency department to determine whether or not an emergency medical condition existed after patient #1 ' s presentation signs and symptoms had changed (change in mentation, weakness and Vital signs) while still on hospital property. The hospital staff was well aware the change in patient #1 ' s medical condition status on 7/29/2014.


9. Interview with the day shift charge nurse on 08./8/2014 at 12:42 PM registration has a scripted guide for persons to be seen in the ER. If the person still wants to be seen, the charge nurse reiterates what registration has told them. If the patient cannot pay but wishes to be seen, the triage nurse would take them back to the triage area to be re-evaluated and speak to the ER doctor. The house supervisor should be notified if person insist on being seen or refuses to leave.
There was no documentation in the medical record to indicate that House supervisor was notified when it was determined that patient #1 needed to be re-evaluated.

10. Interview on 08/08/2014 at 1:08 PM with emergency room physician on duty on 07/29/2014 revealed that with the emergency screening protocol (ESP) if PA does not think it is an emergency then the co-pay has to be paid. The patient makes the decision to be seen after speaking with the registrar if they have no insurance it is a $150.00 flat rate co-payment this includes any lab or x-rays. Anytime the mid-level sees someone if they have a question as to whether or not the person needs to be seen in the ER they will consult with the ER doctor before making the determination. The ER physician reviews all of the mid-level staff charts. Review of the medical revealed that .the ER physician was consulted by the PA but did not examine or see the patient. The hospital failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that a MSE was provided for patient #1on 7/29/2014 regardless of the patient ' s ability to pay after her medical condition had changed while still on hospital property.


11. Interview with the security guard on 09/08/2014 at 3:45 p.m. stated that; I was making rounds in the facility and one of the girls called me to the registration area because they had a patient that had vomited. I went to my office which is located off the registration area, I wear hearing aids so I having a hard time understanding her verbiage, but I was able to hear a lady that was with the patient (patient#1) say that they have examined her. The lady was talking a little loud. I did not hear the patient (patient#1) say anything. I left the area to complete my rounds. I was not contacted to come back to the triage area. When I completed my rounds and came back into the ER area the police were present talking to the patient. I do not know who called the police. The police encouraged the patient to get out of the wheelchair in the triage area and to get into the wheelchair so she could leave the facility. The last time I saw patient#1 she was sitting in the wheelchair outside with Paramedic (#1) and the other nurse.


12. Interview with ER paramedic #1 on 08/08/2014 at 3:49 PM revealed that this patient had already been through triage. I was asked to come out to the registration area by the registration clerk to help get a patient out of a chair and into a wheelchair. Paramedic #2 was requested and he came to assist me move the patient from the chair in the registration into a wheelchair. She could not get out of the chair. I went and got the PA to come to reevaluate the patient again because she was unable to get out of the chair into the wheelchair and she had thrown up while I was present. The PA and charge nurse came to the registration area and saw the patient. They stated that she was okay to leave. I think the charge nurse called the police. The police came and encouraged the patient to get out of the chair and into the wheelchair. We did not have to manually lift her into the wheelchair. She was able to get into the wheelchair with assistance. The patient was sitting with her arm on the arm of the wheelchair and she had her head resting on her arm. Paramedic #2 took her outside in the presence of the police. I cleaned up the vomit and met Paramedic #2 outside. Her family was getting a little confrontational verbally with me and Paramedic #2. The patient was not saying or doing anything. She did not say that she wanted to go anywhere else. Myself and paramedic #2 had difficulty getting the patient from the wheelchair into the car we tried for over a half hour but were unable to get her from the wheelchair into the car. The patient appeared to be very weak. We called and informed the charge nurse of what was going on with the patient and that the family had asked the police to call Emergency Medical Services (EMS) to transfer the patient to another facility. She did not give us any new direction, she just replied okay. Paramedic #2 and I stayed outside with the patient until EMS arrived. EMS had trouble getting the patient out of the wheelchair onto the stretcher. She was lifted into a standing position and the stretcher was placed beneath the patient and she was slid onto the stretcher. The patient left the facility via EMS and paramedic #2 and I came back into the facility. again ,The ER paramedic was asked if he received any guidance when he spoke to the charge nurse, again he stated that no guidance was given other than OK.