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Based on record reviews, policy reviews and patient/staff/physician interviews and review of Security video the facility failed to ensure 1 (Patient 2) of 19 sampled patients received a Medical Screening Examination (MSE) to determine within the hospital's capabilities the presence of an Emergency Medical Condition (EMC) in accordance with the facility EMTALA policies. The staff also failed to follow facility policies for patients requesting to leave Against Medical Advice to ensure the patient was refusing care. The total sample of 20 records, (1 patient had 2 records) was taken from the central logs of patients presenting to the Emergency Department for a MSE from 8/1/20 - 1/20/21. Findings are:

See also A 2406.

A. Review of facility policy titled "Triage" last revised 4/2020 states "Triage is a system of assessing and prioritizing the patients presenting to the Emergency Department." The policy states nursing staff are responsible for the Triage function and are to "Assess all patients presenting to the ED as soon as possible after arrival." The nursing assessment includes "subjective and objective data, pain assessment and vital signs (including pain score). Triage assessments are used to determine the priority/urgency of patients to be seen for a MSE. Emergent (more critical) patients would be taken from Triage to the Main ED for immediate MSE prior to a non emergent patient.

Review of facility policy titled "Emergency Examination and Transfer (EMTALA" last revised 6/2018 states under the section titled "Policy Medical Screening Procedures" that patients are entitled to a MSE. The policy states that "Any patient, who is not otherwise a patient of the Hospital, shall be provided an appropriate MSE within the capabilities of the ED (including ancillary services routinely available to the ED." The policy further states that the MSE is provided to patients who "Upon presentation at a DED [Dedicated Emergency Department] of a Hospital, and upon a request for examination or treatment for a medical condition. Such a request will be considered to exist if a prudent layperson observer would believe, based on the patients appearance or behavior, that the patient needs examination or treatment for a medical condition." The policy also states that "Triage is not equivalent to the MSE: triage determines the order in which patients will be provided a MSE based on the severity of their presenting symptoms."

Review of the facility policy titled "Leaving Against Medical Advice (AMA) Refusal of Care policy last revised 9/2020 states that "if the nurse determines that the patient or the patient's Surrogate is refusing care or withdrawing consent, the nurse shall immediately notify the healthcare provider. The healthcare provider must explain the benefits,risks and alternatives to treatment to the patient or Surrogate and appropriately document such explanation in the electronic medical record (EMR) and on the appropriate AMA or refusal form. If the healthcare provider is not available, then the nurse may relay the information and document in the EMR and on the form." The policy also states that "if the patient or the patient's Surrogate refused to sign the form, an attempt should be made to read the form to the patient or patient's Surrogate and also provide a copy to the patient or patient's Surrogate, if possible." Staff are directed to document in the EMR the reasons for refusal of care and/or leaving in the patient's or patient's Surrogate's own words."

B. Review of ED record for Patient 2 dated 1/20/21 notes the patient arrived by EMS (Emergency Medical Services) at 4:45 PM. Documentation by ED Registered Nurse, ED RN A, notes the patient arrived by EMS ambulance for "abdominal pain." The patient was sent to Triage in the Main DED lobby due to high ED census. Facility provided census report for 4:45 PM shows all ED rooms full except one being cleaned after a COVID patient. RN A documented the patient independently got up from an EMS stretcher and laid in the middle of the floor in the North Tower Lobby Entrance (ED temporary waiting area due to construction). The notes state "Patient was asked to get in a wheelchair to be triaged, patient refused. Patient requesting to leave and have her husband pick her up. Patient ambulated to the North Tower Lobby breeze-way [connects to exit to hospital parking area] to wait for husband. IV [Intravenous catheter placed by EMS prior to arrival] removed at this time. Patient refused to sign AMA paperwork."

The EMR notes the patient left the hospital at 4:50 PM (5 minutes after rescue squad EMS arrival). The AMA form states the patient was refusing a medical screening exam, treatment or care prior to seeing a physician provider. The form states that the purpose of the care or treatment was "to evaluate cause of abdominal pain." Risks of refusing care or treatment are "worsening condition, death, or disability. The alternatives to this care or treatment are "follow up with primary care physician." The section of the form titled "I am refusing this care or treatment because:" is left blank. ED RN A signed the form along with ED RN B, who was also the Charge RN. The EMR documentation review fails to demonstrate the patient had any assessment or MSE to assess her condition and determine if she had an EMC requiring emergency Treatment.

C. Staff interview on 2/2/21 at 1:00 PM with ED Registrar 1 revealed the patient screamed when EMS staff tried to move the patient from their cart to a wheelchair and stated " No I cannot sit, I need to lay down". The patient then laid on the floor by the EMS cart. The Registrar heard ED RN A tell the patient "we have no beds, we'll get you Triaged but you have to sit out here and wait." After that the ED Nurse Aid, ED NA 2 was heard stating to the patient "you need to get into a chair and you will not lay on this floor" in a stern coarse tone of voice. The patient then crawled to a carpeted area and told the Registrar "I need to lay down." NA 2 stated again to the patient "You cannot lay on this floor, for us to get you to a Triage room you must get into a wheelchair". The patient wanted her phone and called her husband to come and get her. The patient got to a bench in the breezeway . ED RN A told the Registrar not to let her go until she got the IV pulled out. Registrar 1 stated Patient 2 "Most definitely looked like she was in need of help. Registrar 1 stated the patient was sweating, hyperventilating and told her "my insides are killing me." Registrar 1 further stated that if she was "on the street and I saw her, I would have definitely called 911."

D. Review of Security video of the ED waiting area and breezeway on 1/20/21 at 4:43 PM shows patient 2 rolled into the North Tower ED lobby entrance by EMS clutching her abdomen. EMS tried to assist the patient to stand from the ED cart and the patient went to the floor on all fours. Registrar A is seen with a wheelchair however the patient crawled and laid down on the floor. ED NA 1 is observed talking to the patient and motioning to the wheelchair. The patient gets her phone and makes a call. The patient gets to a chair and uses it to pull self up while leaning over holding her abdomen. At 4:48 the video shows the patient walking bent over and using the chairs to help support her to the small bench in the breezeway to the exit. She is then observed laying on her side with knees drawn up on the bench. ED RN A appears at 4:49 PM with a strip of gauze. The IV appears to be removed and the nurse left. There were no AMA papers in her hand per the video. The husband arrives at 5:02 PM and helps the patient walk bent over to the car.

E. Interview with ED Nurse Manager RN C 2/2/21 at 2:45 PM revealed that a patient cart will not fit into triage area however staff could have rolled in a recliner for Triage or kept the patient on the EMS cart and Triage the patient while on that. Further interview on 2/4/at 12:55 PM confirmed Patient 2 "did not get a MSE in accordance with our policies."

F. Phone interview with Patient 2 on 2/2/21 at 1:00 PM revealed the patient called EMS due to severe abdominal pain and fever for 2.5 days. She states she could not sit and "felt like I was gonna die." Staff told her "we will not treat you if you won't get up into a chair". She told them she couldn't and had pleaded with her [staff person] stating "I'm very sick don't do this to me let me lay here (on the floor). The staff got people to help me up but she told them not to touch her. She stated she used a chair and hobbled up to the bench near the entrance. Patient 2 said "I called my husband and told him "they won't treat me." I laid there for 10 to 15 minutes crying and afraid. "It was humiliating." A person came up to me in blue and said we "can't let you leave with IV." The person then said to take the bandage off in 20 minutes. Patient 2 said "I never refused care, I was terrified. I wanted treatment." Patient 2 said "I was refused service." The patient stated there was no care provided to her. The patient then said her husband took her to [Name of acute local hospital B] where they treated her pain, nausea and a scan showed she needed surgery.

G. Phone interview with ED MD F on 2/9/21 at 4:50 PM revealed Patient 2 arrived at their ED at 5:22 PM on 1/20/21 with complaint of abdominal pain. The appearance of the patient per ED MD F was that of a patient "in severe distress with significant pain." ED MD F recalled the patient was very cooperative but had a great deal of difficulty to sit. The patient had stated that she had been to another hospital and they"wouldn't see her as not able to sit." ED MD F stated that Patient 2 had an EMC requiring immediate stabilizing treatment in the ED. Concerns were her increased pain. A CT (Computerized Tomography scan that provides pictures of internal organs, bones and other tissues) showed acute appendicitis with localized peritonitis.

Based on record reviews, policy reviews and patient/staff/physician interviews and review of Security video the facility failed to ensure 1 (Patient 2) of 19 sampled patients was provided a Medical Screening Examination (MSE) to determine within the hospital's capabilities the presence of an Emergency Medical Condition (EMC). The total sample of 20 records, (1 patient had 2 records) was taken from the central logs of patients presenting to the Emergency Department for a MSE from 8/1/20 - 1/20/21. This failure has the potential for all patients presenting to the Emergency Department (ED) to have an untreated MSE which could result in harm or death due to delay in treatment. According to facility provided information the ED sees an average of 2,409 patients per month. Findings are:

A. Review of EMS documentation titled "Patient Care Report" on 1/20/21 shows Emergency Medical Technicians (EMT) - Paramedics [Name of EMT 3 and 4] arrived to the home of Patient 2 for a patient complaining of Abdominal Pain at 4:28 PM. Narrative notes state the patient was "in the fetal position on the floor, complaining of sharp, lowered abdominal pain." The notes document the pain began 1 day prior. The patient had a history of diverticulitis [inflammation of abnormal pouches in the intestine], and felt the pain was similar. The patient also reported a fever. Vitals were "stable" but not noted on the form. The patient was assisted to the stretcher (EMS cart) and and Intravenous (IV) line was established. The patient had no change in pain enroute. On arrival the report states the patient "refused to get into a wheelchair, stated she needed to lay down. Pt [patient] laid on the floor, transferred med [medical] info [information] and care to nursing staff." They left at 4:44 PM.

B. Phone interview with EMT 3 and 4 on 2/4/21 at 11:30 AM revealed that on arrival Patient 2 had pain 10/10 (maximum pain score on 1 of 10 scale). They said the patient had a possible EMC related to an abdominal issue so they inserted an IV. The EMT's said it is rare that they have to take a patient through the Main Lobby of the ED but it was due to construction issues. They said if they come in by the ambulance bay door, they would have had to take her to Triage. They tried to get the patient to a wheelchair but the patient said she was unable to sit and was told there were no beds available. The EMT's stated staff told her you "have to sit in wheelchair to evaluate you." The patient got off the cart and laid on the floor. Nurse told her "we have to get you into wheelchair to get you triaged." When the EMT's left the patient had said she was leaving and was "on her feet bent over holding onto chairs." The EMT's stated "care was not given cause she couldn't get into a chair."

C. Review of ED record for Patient 2 dated 1/20/21 notes the patient arrived by EMS (Emergency Medical Services) at 4:45 PM. Documentation by ED Registered Nurse, ED RN A, notes the patient arrived by EMS ambulance for "abdominal pain." The hospital directed EMS to take the patient to Triage in the Main Dedicated Emergency Department (DED) lobby due to high ED census. normal EMS procedure is to take the patient directly to a patient room in the ED for examination/treatment. Facility provided census report for 4:45 PM shows all ED rooms full except one being cleaned after a COVID patient. A walk in chest pain was in Triage waiting for that room. RN A documented the patient independently got up from an EMS stretcher and laid in the middle of the floor in the North Tower Lobby Entrance (ED temporary waiting area due to construction). The notes state "Patient was asked to get in a wheelchair to be triaged, patient refused. Patient requesting to leave and have her husband pick her up. Patient ambulated to the North Tower Lobby breeze-way [connects to exit to hospital parking area] to wait for husband. IV [Intravenous catheter placed by EMS prior to arrival] removed at this time. Patient refused to sign AMA (leaving Against Medical Advice) paperwork."

The EMR notes the patient left the hospital at 4:50 PM (5 minutes after rescue squad EMS arrival). The AMA form states the patient was refusing a medical screening exam, treatment or care prior to seeing a physician provider. The form states that the purpose of the care or treatment was "to evaluate cause of abdominal pain." Risks of refusing care or treatment are "worsening condition, death, or disability. The alternatives to this care or treatment are "follow up with primary care physician." The section of the form titled "I am refusing this care or treatment because:" is left blank. ED RN A signed the form along with ED RN B, who was also the Charge RN. The EMR review fails to find any documentation of vitals, any nursing assessment or MSE which could have determined if the patient had an EMC requiring immediate stabilizing treatment.

D. Review of Security video of the ED waiting area and breezeway on 1/20/21 at 4:43 PM shows patient 2 rolled into the North Tower ED lobby entrance by EMS clutching her abdomen. EMS tried to assist the patient to stand from the ED cart and the patient went to the floor on all fours. Registrar A is seen with a wheelchair however the patient crawled and laid down on the floor. ED NA 1 is observed talking to the patient and motioning to the wheelchair. The patient gets her phone and makes a call. The patient gets to a chair and uses it to pull self up while leaning over holding her abdomen. At 4:48 the video shows the patient walking bent over and using the chairs to help support her to the small bench in the breezeway to the exit. She is then observed laying on her side with knees drawn up on the bench. ED RN A appears at 4:49 PM with a strip of gauze. The IV appears to be removed and the nurse left. There were no AMA papers in her hand per the video. The husband arrives at 5:02 PM and helps the patient walk bent over to the car.

E. Review of the EMR for Patient 2 from local acute care Hospital B dated 1/20/21 shows the patient presented there shortly after leaving Methodist Hospital arriving at 5:29 PM to the ED. ED Medical Doctor (MD ) F performed the MSE finding the patient who presented with severe abdominal pain had acute appendicitis with peritonitis (inflammation of the lining of the inner wall of the abdomen causing severe pain. Complications may include shock). The patient was given pain medication, anti nausea medication and a bolus of IV fluid. Surgery 1/21/21 found a ruptured appendix with peritonitis.

Phone interview with ED MD F on 2/9/21 at 4:50 PM revealed Patient 2 arrived at their ED (Hospital B) at 5:22 PM on 1/20/21 with complaint of abdominal pain. The appearance of the patient per ED MD F was that of a patient "in severe distress with significant pain." ED MD F recalled the patient was very cooperative but had a great deal of difficulty to sit. The patient had stated that she had been to another hospital and they"wouldn't see her as not able to sit." ED MD F stated that Patient 2 had an EMC requiring immediate stabilizing treatment in the ED. Concerns were her increased pain. A CT (Computerized Tomography scan that provides pictures of internal organs, bones and other tissues) showed acute appendicitis with localized peritonitis.

F. Interview with ED RN A on 2/3/21 at 8:25 AM. RN A was the assigned Triage RN on 1/20/21. ED RN A stated the normal process is EMS calls into ED with chief complaint, priority code, Vital signs and any ED nurse takes the call and documents it. Ambulances use the ambulance entrance and are directed where to go from there. If no rooms available can use hallway. If rooms are full it is the decision of the RN to get gurney (cart) in hall or direct the patient to Triage. There are 3 chairs in Triage. Can also send to the waiting room in a chair or wheelchair.

ED RN A recalled getting report on Patient 2. ED Nurse Aid (ED NA 2) was the primary person to help Patient 2 off the EMS cart. ED RN A was getting report from the EMT as ED NA 2 was helping her. She recalled hearing the patient say "I am in too much pain, I need a bed". She heard ED NA 2 tell the patient there was no bed available and needed to get into a wheelchair or a lobby chair. She recalled the patient being on the floor and telling the NA not to touch her. The patient said she was "calling her husband to come pick me up." ED RN A spoke to the patient from the front desk and reinforced to the patient that "she needed to get into a wheelchair to be triaged." The patient said "No in too much pain and needed a bed." It seemed that since a bed was not available for her she didn't want to wait until she had a bed." ED RN A spoke to the patient while laying on the bench in the breeze way area near the exit to the parking area. ED RN A asked her to sign AMA form and the patient told her "I'm not signing anything."
ED RN A said she told the patient if she felt worse or had a worsening condition to come back.

ED RN A confirmed she did not want to ask the patient any questions while in the waiting room area due to confidentiality (HIPPA) issues. When asked if the patient appeared to have a potential EMC ED RN A responded "yes, she was in pain, I didn't see her cry, didn't feel hot to the touch or appear flushed".

G. Interview with ED NA 2 on 2/2/21 at 1:30 PM. The NA stated her role is to settle patients and getting vital signs, ensure they are comfortable in a wheelchair or chair. She also draws lab, assists the providers and nurses with procedures and tasks, and transports patients. The NA recalled Patient 2 arriving by EMS to Triage in our Main ED entrance area. She greeted the patient on arrival. The patient told her she "needed a bed to lay in and was in pain." ED NA 2 did not ask where the pain was but noted the patient "looked in distress, curled up in fetal position holding stomach." She went from the gurney (EMS cart) to the floor and ED NA 2 recalled telling her she "needed to sit in a wheelchair or chair." The patient said she would rather lay on the floor. ED NA 2 stated she told Patient 2 she "could not start vital signs or triage until she was in a chair." The NA stated that if they have one available they can get a gurney from the ED but had none available. The patient told her she was calling her husband, stood up and went out to the bench. She recalled EN RN A saw Patient 2 on the bench outside the ED and went out to take the IV out.

H. Staff interview on 2/2/21 at 1:00 PM with ED Registrar 1 revealed the patient screamed when EMS staff tried to move the patient from their cart to a wheelchair and stated " No I cannot sit, I need to lay down". The patient then laid on the floor by the EMS cart. The Registrar heard ED RN A tell the patient "we have no beds, we'll get you Triaged but you have to sit out here and wait." After that the ED Nurse Aid, ED NA 2 was heard stating to the patient "you need to get into a chair and you will not lay on this floor" in a stern coarse tone of voice. The patient then crawled to a carpeted area and told the Registrar "I need to lay down." NA 2 stated again to the patient "You cannot lay on this floor, for us to get you to a Triage room you must get into a wheelchair". The patient wanted her phone and called her husband to come and get her. The patient got to a bench in the breezeway .While on the bench ED Registrar 1 gave her a blanket. The patient said I "can't get comfortable, my insides are burning up." ED RN A told the Registrar not to let her go until she got the IV pulled out. Registrar 1 stated Patient 2 "Most definitely looked like she was in need of help. Registrar 1 stated the patient was sweating, hyperventilating and told her "my insides are killing me." Registrar 1 further stated that if she was "on the street and I saw her, I would have definitely called 911."

I. Interview with ED Core (Charge) nurse, ED RN B on 2/3/21 at 2:35 PM. Note ED RN B co signed the AMA paper for Patient 2 on 1/20/21. ED RN B recalled she was "Notified by [name of ED RN A] after the fact - patient came by ambulance with abdominal pain and didn't want to stay and husband picked up." ED RN B said the nurse "might have mentioned due to no ED bed open for her at arrival." Encode from EMS enroute was that the patient had 10/10 abdominal pain Blood pressure 150/100 (elevated normal 120/80), pulse 96. ED RN B stated this "would lead person to believe patient may have an EMC." ED RN B said it is normal for Triage to be predicated on the patient's ability to get into a wheelchair. If the patient was on the floor and pulseless they would start the assessment on the floor. On 1/21/20 it was a busy day 40 % of ED patients were admitted versus the usual 33 %. If a patient cannot sit staff can use a recliner in triage as there are partitions in triage for 3 patients. In reviewing Patient 2's visit ED RN B stated it appears the patient was "not offered a MSE." ED RN B further stated that staff "could have brought the patient into the triage room to sit in the blood draw recliner. Don't think we had the chance to provide the standard of care." ED RN B confirmed the ED was not on diversion (unable to accept ambulance patients due to availability of beds) on 1/21/21.

J. Interview with ED Nurse Manager RN C 2/2/21 at 2:45 PM revealed that a patient cart will not fit into triage area however staff could have rolled in a recliner for Triage or kept the patient on the EMS cart and Triage the patient while on that. Further interview on 2/4/at 12:55 PM confirmed Patient 2 "did not get a MSE in accordance with our policies."

K. Phone interview with Patient 2 on 2/2/21 at 1:00 PM revealed the patient called EMS due to severe abdominal pain and fever for 2.5 days. She states she could not sit and "felt like I was gonna die." Staff told her "we will not treat you if you won't get up into a chair". She told them she couldn't and had pleaded with her [staff person] stating "I'm very sick don't do this to me let me lay here (on the floor). The staff got people to help me up but she told them not to touch her. She stated she used a chair and hobbled up to the bench near the entrance. Patient 2 said "I called my husband and told him "they won't treat me." I laid there for 10 to 15 minutes crying and afraid. "It was humiliating." A person came up to me in blue and said we "can't let you leave with IV." The person then said to take the bandage off in 20 minutes. Patient 2 said "I never refused care, I was terrified. I wanted treatment." Patient 2 said "I was refused service." The patient stated there was no care provided to her. The patient then said her husband took her to [Name of acute local hospital B] where they treated her pain, nausea and a scan showed she needed surgery.

L. Review of facility policy titled "Emergency Examination and Transfer (EMTALA" last revised 6/2018 states under the section titled "Policy Medical Screening Procedures" that patients are entitled to a MSE. The policy states that "Any patient, who is not otherwise a patient of the Hospital, shall be provided an appropriate MSE within the capabilities of the ED (including ancillary services routinely available to the ED." The policy further states that the MSE is provided to patients who "Upon presentation at a DED [Dedicated Emergency Department] of a Hospital, and upon a request for examination or treatment for a medical condition. Such a request will be considered to exist if a prudent layperson observer would believe, based on the patients appearance or behavior, that the patient needs examination or treatment for a medical condition."