HospitalInspections.org

Based on review of medical records, Medical Staff Rules and Regulations, policy and procedures, video surveillance, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) 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 for one (P#1) of 20 sampled patients when she was transported to the ED on 11/24/23. Family members requested that P#1 be evaluated for behavioral health symptoms.


Refer to findings in Tag A-2406.

Based on review of the Emergency Department Log, video surveillance, facility policies and staff interviews, it was determined the facility failed to maintain a central log on P#1 who came to the emergency department seeking medical assistance, when she was transported to the ED on 11/24/23 by family members for evaluation of behavioral health symptoms.

The findings included:

A review of the facility's Emergency Department log failed to reveal an entry for P#1 on 11/24/23.

Video surveillance was requested concerning Patient (P) #1. A review of the video surveillance provided took place in the security office with Public Safety Officer (PSO) AA on 12/4/23 at 4:30 p.m. The following timeline was observed from 11/24/23:

8:28:43 - A white sport-utility vehicle (SUV) with darkly tinted windows pulled into the ambulance bay.
8:33: 12 - The driver's side rear window was lowered, and it was observed that a person was flailing her arms outside the window.
8:33: 57 - Staff identified as RN CC and Patient Care Technician (PCT) DD were observed coming out of the ED.
8:34:58 - RN CC was observed at the rear window of the vehicle. PSO AA said RN CC was talking to the female in the back seat of the vehicle.
8:36:34 - The individual in the back seat was observed hanging out of the window.
8:38:48 - The male family member got out of the car and forced the female in the back seat back into the car.
8:39:10 - The vehicle pulled away from the ED.

A review of the facility's policy titled "Transfer Activities in Accordance with EMTALA Requirements Policy" #11101630, last revised 1/27/22 revealed that with respect to an individual requesting examination or treatment for an emergency medical condition (EMC), the individual "came to the Emergency Department" when the individual was on hospital property or within 250 yards of the main building, including parking decks/lots, sidewalks, and driveways. The ED would maintain a central log on everyone who came to the emergency department seeking assistance, which would include whether the patient refused treatment, was refused treatment, transferred to another facility, was admitted and treated, was stabilized and transferred, or was discharged.

An interview took place with the Public Safety Officer (PSO) AA on 12/4/23 at 3:55 p.m. in the Conference Room. PSO AA said a car pulled into the ambulance bay, and he and PSO BB walked outside to the vehicle. A man got out of the vehicle and was speaking to the Registered Nurse (RN) CC, saying his daughter was having a breakdown and was out of control. The rear window of the car was lowered, and RN CC asked the patient's name, date, and if she knew where she was.

A telephone interview took place with the Registered Nurse (RN) CC on 12/4/23 at 4:44 p.m. RN CC said she did not get P#1's name because P#1 never came into the ED. The policy was that patient's had to be present at the desk to be put on the log. RN CC said she asked P#1 orientation questions, but information was never put into the system.

The facility failed to ensure that their Policy and procedure was followed as evidenced by failing to ensure that when Patient #1 came to the hospital's ED, the hospital failed to maintain a central log on patient #1 seeking medical assistance for a medical condition.

Based on review of medical records, Medical Staff Rules and Regulations, policy and procedures, video surveillance, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening examination (MSE) 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 for one (P#1) of 20 sampled patients when she was transported to the ED on 11/24/23. Family members requested that P#1 be evaluated for behavioral health symptoms.

The findings included:

A review of the Medical Staff Rules and Regulations, Section 5, Medical Screening Exam for Emergency Department (ED), revealed that any patient who requested examination or treatment would receive an appropriate medical screening examination within the capacity of the emergency department to determine whether an emergency existed.

A review of the facility's "Transfer Activities in Accordance with EMTALA Requirements Policy" #11101630, last revised 1/27/22, revealed that it was the policy of the facility to provide an appropriate medical screening examination (MSE), stabilizing treatment, and/or an appropriate transfer. With respect to an individual requesting examination or treatment for an emergency medical condition (EMC), the individual "came to the Emergency Department" when the individual was on hospital property or within 250 yards of the main building, including parking decks/lots, sidewalks, and driveways.

Continued review of the policy revealed that an emergency medical condition was a condition manifesting itself by acute symptoms of such severity, including pain, psychic disturbances, or symptoms of substance abuse, that the absence of immediate medical attention could reasonably be expected to place the health of the individual in serious jeopardy.

The policy revealed that Involuntary Status applied equally to patients with psychiatric or drug/alcohol related conditions. Such patients who presented to the ED would receive a medical screening examination and stabilizing treatment. If their condition remained unstable, an appropriate transfer would be arranged. The appropriate involuntary transfer forms (1013,2013) were required to be utilized and completed in addition to the hospital transfer forms. No consent for transfer from the patient was required.

Video surveillance was requested concerning Patient (P) #1. A review of the video surveillance provided took place in the security office with the Public Safety Officer (PSO) AA on 12/4/23 at 4:30 p.m. The following timeline was observed from 11/24/23:

8:28:43 - A white sport-utility vehicle (SUV) with darkly tinted windows pulled into the ambulance bay.
8:33: 12 - The driver's side rear window was lowered, and it was observed that a person was flailing her arms outside the car window.
8:33: 57 - Staff identified by PSO AA as RN CC and Patient Care Technician (PCT) DD were observed coming out of the ED.
8:34:58 - RN CC was observed at the rear window of the vehicle. PSO AA said RN CC was talking to the female in the back seat of the vehicle.
8:36:34 - The individual in the back seat was observed hanging out of the window. PSO AA said the individual was screaming. The deputy and the father were observed standing behind the vehicle. PSO AA said the deputy and father were talking, but he could not hear the conversation.
8:37:10 - CD EE and the father were observed walking to the rear passenger door. PSO AA said the dad pushed the girl back into the vehicle.
8:38:01 - The father got into the car. The individual was still hanging out of the window.
8:38:48 - The father got out of the car and forced her back into the car.
8:39:10 - The vehicle pulled away from the ED.

Further review revealed that Patient #1 was taken to another hospital by her parents. Review of the medical record revealed that patient #1 arrived at the other hospital on 11/24/2023 at 8: 52 P.M. The reason for the hospital visit was listed as "MENTAL HLTH (Health)." Further review revealed in part, "History and Present Illness ... female with history of panic attacks, meth (methamphetamine recreational drug) and THC (Marijuana) abuse presents to ER (emergency room) intoxicated and appearing manic, received Haldol (drug used to treat symptoms of agitation, irritability and delirium) 5mg/Versed (drug used to treat anxiety and tension) 5 mg IM (intramuscular) on arrival for acute agitation. UDS (Urine Drug Screen) + (positive) meth & THC. Patient was observed by ER team overnight and reassessed after some metabolization of substance, however, on reassessment still appeared pressured speech in speech, agitated, and delusional so psychiatry consulted ...She states has anxiety and PTSD (Post Traumatic Distress Disorder-an anxiety disorder that develops after experiencing or witnessing a terrifying event) but marijuana is only this that makes it better." Review of the medical record titled "Discharged." Patient #1's Discharge Diagnosis was listed as "Methamphetamine use (other stimulates abuse, uncomplicated)." Further review revealed in part, "Hospital Course ... In reassessment on 11/26/2023, patient denies SI (suicidal ideation)/HI (Homicidal Ideation)/AVH (Audio visual hallucinations) ...Agreeable to take Zyprexa 2.5 mg PO (by mouth) QHS (every night) and follow-up with outpatient psychiatry.." The patient was discharged from the hospital on 11/26/2023.


An interview took place with the Public Safety Officer (PSO) AA on 12/4/23 at 3:55 p.m. in the Conference Room. PSO AA said a car pulled into the ambulance bay, and he and PSO BB walked outside to the vehicle. A man got out of the vehicle and was speaking to the Registered Nurse (RN) CC, saying his daughter was having a breakdown and was out of control. The rear window of the car was lowered, and RN CC asked the patient's name, date, and if she knew where she was. RN CC then asked the patient if she wanted to be treated, and the patient said no. The patient's mother demanded the nurse remove the patient from the vehicle and treat her, but if the patient was declining treatment, she could not be forced. The patient started throwing shoes out the window and screaming obscenities. When the nurse said she would not pull the patient out of the car, the father said to get someone else. The nurse went into the Emergency Department (ED). RN CC came back and said the doctor would not come out. The patient would have to enter the ED to be seen. The patient said she was not going in and did not want to be treated. PSO AA heard the patient say she should just go kill herself, and that she was going to do a gang dance on all their faces. The patient was saying random things that did not make sense. PSO AA said he heard the deputy say the other hospital had a better facility and staff that could handle that. The patient was trying to get out of the vehicle and was screaming, cursing, and threatening.

A telephone interview took place with the Registered Nurse (RN) CC on 12/4/23 at 4:44 p.m. RN CC said she did not get P#1's name on a log, because P#1 never came into the ED. RN CC asked P#1 her name, date of birth, where she was, and what was going on. There was a lot of shouting on P#1's part, because P#1 was upset that her parents brought her to the ED. RN CC asked P#1 several times if she wanted to be seen, and P#1 declined every time she was asked. The mom was pleading for them to get P#1 out of the vehicle and make her be seen. RN CC informed the mom that the Nurse Practitioner (NP) DD said if P#1 was willing to check in, the ED was more than willing to avail their services, but they could not force care upon her.

A telephone interview took place with the off-duty, contracted deputy (CD) EE on 12/4/23 at 5:15 p.m. CD EE said he was sitting in a cubicle near the ED when somebody called to say they were bringing their daughter into the ED. When they pulled up, there was a girl in the back of the vehicle. The parents were asking for her to be seen. The doctor said they were not coming outside to evaluate the patient. CD EE told the dad that she could not be snatched out of the car against her will without a 1013 (involuntary transport order), because it would be kidnapping. All law enforcement hands were tied without a 1013. The individual was screaming and cursing.

An interview took place with the Registered Nurse (RN) II while on a tour of the Emergency Department (ED) on 12/5/23 at 9:30 a.m. RN II said if a patient would not enter the ED, she would get the patient's information and try to get a provider to come outside to screen them.

An interview took place with the Nurse Practitioner (NP) JJ while on a tour of the ED on 12/5/23 at 9:30 a.m. NP JJ said he would go outside to evaluate a patient who was refusing to come into the ED.

An interview took place with the ED Nurse Manager (RN) FF on 12/5/23 at 10:33 a.m. in the Conference Room. RN FF said it would have been normal for a doctor to go outside to see the patient. RN CC wanted to make sure the patient was alert, oriented and answered questions, but it still should have been the provider. RN FF further said the staff would ask the patient directly if she had thoughts of harming herself, and if so, she would be asked if there was a plan.

An interview took place with the ED Medical Director (DO) GG on 12/5/23 at 10:37 a.m. in the Conference Room. DO GG said the staff could not drag people out of cars who refused care. Patients had the right to refuse treatment. If there was an imminent threat to life or limb that needed emergent evaluation, DO GG would expect the medical staff to be outside evaluating the patient. The doctor would not be expected to go out or security drag a patient in unless the situation needed emergent care. The nurse would say if she needed a clinician outside. DO GG further said the ED had an obligation to provide care to those who presented seeking care.

An interview took place with the Public Safety Officer (PSO) HH on 12/5/23 at 11:18 a.m. in the Conference Room. PSO AA said that when he arrived on the scene, an individual was in the back of a car acting irate. A lady came out in blue scrubs and asked the individual her name, etc. The lady told the parents if the patient refused medical attention, there was nothing they could do. The doctor said to bring the patient in, but if she was refusing, they could not make her come in. The patient was saying she wanted to walk on their faces and all kinds of stuff. PSO HH said everybody in the vicinity, including RN CC, should have heard when P#1 said she wanted to kill herself. PSO HH said the way the patient was carrying on, she seemed like a threat to herself. RN CC asked the individual her name and where she was, and the individual answered. The individual threw her shoes out of the car and was kicking the window, so PSO HH backed away and did not hear everything that was said.

A telephone interview took place with the Patient Care Technician (PCT) DD on 12/5/23 at 2:00 p.m. PCT DD said the nurse asked the patient what was going on and if she wanted to be seen. The patient said no. RN CC was asking orientation questions, which were answered appropriately. RN CC asked the patient if she wanted to get into a wheelchair and come into the ED, and the patient said no. The patient was yelling, stopped to answer the nurse's questions, then continued to yell. The police officer spoke to the father, and then the patient and father drove away from the ED. PCT DD could not hear what was being discussed when the police officer spoke with the father.

A telephone interview took place with the Nurse Practitioner (NP) HH on 12/5/23 at 2:15 p.m. NP HH said the nurse told him there was an adult female who was having mental health problems who did not want to get out of the car. NP HH said that based on the nurses' report, it sounded like the patient had the capacity to make her own decisions and refused to get out of the car. If she wanted to come in to be evaluated, the ED would be more than happy to see her. NP HH said it was not routine to evaluate patients before they were registered, and it did not seem that the patient was in a state that it was imperative that she be evaluated.

The facility failed to ensure that their own policies and procedures were followed as evidenced by failing to ensure that on 11/24/23 Patient #1 presented to the hospital's property (ambulance bay) via family's SUV manifesting symptoms of "psychic disturbances" that in absence of immediate medical attention could reasonably be expected to place the health of an individual in serious jeopardy. The patient presented to the ED indicating she wanted to kill herself. As Patient #1 required further evaluation and treatment to determine if the patient was an imminent harm to herself and others. The patient was not placed on an involuntary hold, and no measures were taken by the ED staff to bring Patient #1 into the ED to receive an appropriate medical screening examination.