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Based on facility policy review, medical record review, video footage, and staff interview, the hospital failed to provide an appropriate medical screening exam (MSE) by failing to register and evaluate Patient #4 that presented to the Emergency Department via medical transport, and failed to provide a MSE for Patient #6. This affected 2 of 22 sampled patients who presented to the Emergency Department, (Patient #4 and Patient #6).

Findings included:

Refer to A2406 for findings.

Based on reviews of the hospital policies and procedures, central log, and interview, the facility failed to include each individual on a log who presented to the emergency department seeking assistance. On 07/01/2022 Patient #4 presented to the emergency department via Emergency Medical Services, but was not listed on the central log. This affected one (1) of 22 sampled patients, (Patient #4).

Findings included:

Review of the hospital's policy and procedure titled, "Emergency Medical Treatment and Labor Act (EMTALA), 13.0" reviewed 04/2020 revealed "... Central Log; A central log will be maintained on each individual who comes to the Emergency Department or the hospital seeking treatment for an Emergency Medical Condition. The log will show the disposition of the individual - admission, stabilization, refusal of treatment, transfer or discharge. The log of the obstetrical patient who is medically screened in the Labor and Delivery Department is maintained in the outpatient log. These logs will be maintained a minimum of 5 years ..."

Review of the hospital's central log revealed Patient # 4 was not listed on the log as presenting via ambulance transport service on 07/01/2022.

Interview on 07/13/2022 at 1420 with the interim Emergency Department (ED) Director revealed Emergency Medical Service (EMS) brings patients into the ED, the patient gets registered and depending on the chief complaint the patient is either bedded in an ED room or sent out to triage to wait for a bed to become available. Interview revealed all patients that either come in via EMS or that come in through the ambulatory entrance are placed on the EMTALA central log. Interview revealed the interim ED Director was not aware Patient #4 had presented on 07/01/2022 and was not evaluated nor placed on the EMTALA log for that day. Interview revealed the ED Director, after reviewing Patient #4's ED visit dated 07/02/2022, verified Patient #4 presented to the ED on 07/01/2022 via medical transport service.

Cross refer to Medical Screening Exam - Tag A2406.

Based on facility policy review, medical record review, emergency medical services records, video footage, and staff interview, the hospital failed to provide an appropriate medical screening exam (MSE) by failing to register and evaluate Patient #4 that presented to the Emergency Department via medical transport on 07/01/2022, and failed to provide a MSE for Patient #6. This affected two (2) of 22 sampled patients who presented to the Emergency Department, (Patient #4 and Patient #6).

Findings included:

Review of the facility policy, Medical Screening Exam, effective 12/2020, revealed, "... Every patient who comes to the Emergency Department requesting emergency services will receive a medical screening examination, performed by individuals qualified to perform such examinations, to determine whether an emergency medical condition exists..."

1. Review of the (Name) Medical Transport record dated 07/01/2022 at 1458 revealed Patient #4 was an 87-year-old male transported from his home and arriving in the DED (Dedicated Emergency Department) on 07/01/2022 at 1541. Review revealed "Primary Impression: Generalized Weakness ... Chief Complaint: going for hospice end of life care ... Signs & Symptoms: Generalized Symptoms - Weakness ... Assessment ... Pelvis/GU (genitourinary)/GI (gastrointestinal): Left Hip radiating down to leg ... Pelvis/GU/GI: Pain..." Continued review revealed "... During transport, EMT's (Emergency Medical Technician) were informed by Dispatch that the destination had changed to the (Hospital A) ER (Emergency Room)...While in route, Driver EMT called Dispatch twice to confirm that the charge nurse was expecting us @ (at) (Hospital A). Dispatch confirmed both times that we were being expected ... Upon arrival to (Hospital A) ER, PT (patient) was transported via stretcher from the ambulance to inside the hospital by 2 EMT's. Upon arriving inside hospital ER, Hospital Staff were asking who was the PT. The EMT's notified hospital ER Staff that this was a PT that was going to (Facility B) for hospice but was redirected to (Hospital A) ER due to there was no room availability @ (Facility B) for PT. Dispatch had notified hospital staff of the diversion to their hospital. Hospital staff notified EMT's that the PT shouldn't be there without his Hospice nurse present. Hospital staff also noted that they had contacted hospice nurse of the situation. Hospital staff called hospital social worker that made the call to hospice nurse to give clarification to the EMT's. Upon hospital social worker arriving in ER, Social worker had hospice nurse on call via cellular device, and handed phone to one of the (Name) EMT's. EMT asked hospice nurse if they needed us to wait with the PT in ER until hospice nurse arrival or if they preferred something else. Hospice nurse notified EMT's to take the PT back to his residence. EMT's confirmed that Hospice Nurse wanted us to take PT back to his Residence, which got confirmed by Hospice Nurse. Dispatch was notified that PT was to head back to PT Residence and Dispatch copied and dropped a return run. Throughout these events, PT remained on stretcher secured with 4 straps and 2 side rails." Review revealed the emergency medical services (EMS) call was closed out as complete at 1604.

Review of the (Name) Medical Transport record dated 07/01/2022 at 1604 revealed "... Hospice Nurse notified EMT's to transport the PT back to his residence. The PT was found lying in a stretcher secured by 4 straps and 2 side rails, in the locked position. The PT was transported via stretcher from the hospital to inside the ambulance by 2 EMT's ...Upon arrival to PT Residence, PT was unloaded from ambulance and placed close to his front door. Pt was assisted in getting off the stretcher and assisted in going up his stairs and into his living room couch. PT Care was passed to PT self care..." Review revealed the EMS call was closed at 1621.

Review of the hospital medical record for Patient #4 revealed there was no documentation of Patient #4 presenting to the DED on 07/01/2022 and there was no triage or medical screening exam.

Interview on 07/13/2022 at 1537 with Registered Nurse (RN) #9 revealed she was the Charge Nurse in the ED when Patient #4 arrived by medical transport and remembered both visits. Interview revealed Hospice called saying the patient was coming in and that he was dying and not going to make it but a couple of hours and needed pain management. Interview revealed when Patient #4 arrived, he was alert and oriented, not looking like someone who was going to die in a couple of hours. Interview revealed the Hospice coordinator was contacted and she instructed the ED staff to not see Patient #4, do not take him off the stretcher, and to send him home. Interview revealed RN #9 documented on a note card information she received from the telephone call and when Patient #4 was not seen the note card was shredded as no visit record was created for Patient #4 on 07/01/2022. Interview revealed Patient #4 returned to the ED on 07/02/2022 (19 hours and 5 minutes after leaving first visit) for a fall.

Telephone interview on 07/15/2022 at 1553 with the Hospice Patient Care Manager #10 and Hospice Nurse #11 revealed Patient #4 was originally going to a Facility B for better control of his pain, however Patient #4 had expressed suicidal ideations to Hospice Nurse #11 and the transport was rerouted to the (Hospital A) Emergency department. Interview revealed Hospice Patient Care Manager #10 contacted the Dedicated Emergency Department (DED) Charge Nurse to let her know what was going on and why Patient #4 was coming to the DED. Interview revealed Patient #4 stated to Hospice Nurse #11, " (Name) I thought about ending it all last night. " Interview revealed Hospice Nurse #11 assessed further into if Patient #4 had a means and/or plan and Patient #4 expressed a means. Interview revealed at that time Hospice Nurse #11 notified Hospice Patient Care Manager #10 and the decision was made to reroute the transport to (Hospital Name) Emergency Department for a psych evaluation. Interview revealed once Patient #4 arrived to the ED, he was told he would have to sit and wait and he did not want to wait. Interview revealed the Hospital ED staff could not give Patient #4 any information regarding how long he would have to wait.

Telephone interview on 07/26/2022 at 1840 with EMT #12 revealed he transported Patient #4 to the (Hospital A) Emergency department (ED) on 07/01/2022. EMT #12 stated, Patient #4 was picked up from home and originally was to be transported to (Facility B). Interview revealed during transport the (Name) Medical Transport Dispatch called the EMS truck to reroute from going to (Facility B) to go to (Hospital A) ED. Interview revealed the (Name) Medical Transport Dispatch called the (Hospital A) ED charge nurse to notify her Patient #4 was coming. Interview revealed EMT #12 verified three times with dispatch the (Hospital A) ED charge nurse was aware of Patient #4 coming to the ED. Interview revealed upon arrival to the ED, EMT #12 was questioned on who the patient was as if they did not expect the patient's arrival. Interview revealed EMT #12 was told by a hospital staff member that Patient #4 was not to be in the ED without the hospice nurse accompanying him. Interview revealed the hospital social worker came to the ED with telephone, stating she had gotten a hold of the hospice nurse. Interview revealed the person on the other end of the telephone that was identified by the social worker as the hospice nurse told EMT #12 to take Patient #4 back to his residence. Interview revealed no vital signs were taken in the ED, Patient #4 did not get triaged, and no one from the hospital assessed Patient #4 the entire time they were in the ED. Interview revealed EMT #12 contacted the (Name) Medical Transport Dispatch to let them know they were told to transport Patient #4 back to his residence and that is what they did.



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2. Review of the facility policy, Discharges from the Emergency Department, effective 03/2021, revealed, "... If the patient chooses to leave Against Medical Advice (AMA), they will be asked to sign the Against Medical Advice form. The Emergency Department physician should inform the patient of his/her risk in deciding to leave AMA including threat to limb or life. A nurse will be present as a witness. The same should be documented on the Emergency Department record, as well as on the AMA form. This form, plus documentation, will remain a part of the patient's medical record. In the event the patient refuses to sign the form, the refusal will be documented on the form and in the patient's ED record..."

Closed medical record review of Patient #6 revealed a 2-year-old female who presented to the DED (Dedicated Emergency Department) on 06/30/2022 at 2057 with a chief complaint of "fire ant reaction." Review of the Triage Note by ED RN #5 at 2102 revealed, "Father reports that 30 minutes PTA (prior to arrival), pt (patient) was playing in the driveway, when she stepped into the yard and stepped on a fire ant nest. Mother states she put topical Benadryl on the bites, but noted a generalized reaction. Pt alert and interactive, resps (respirations) even and unlabored, skin w/p/d (warm, pink, dry). No drooling noted. Pulse - 134 H (high), Respiratory Rate - 25 H, Pulse Oximetry - 94% L (low) on Room Air, Temperature - 98.1F (Fahrenheit), Pain Level - 3 FLACC (Face, Legs, Activity, Cry, Consolability - 0-10 behavioral based pain scale for pediatric patients)..."

Recorded review revealed Patient #6 was placed in the waiting room at 2105.

Review of the Departure Assessment by ED Supervisor #4 dated 07/05/2022 at 2349 revealed, "Left Prior to MSE (medical screening exam), recognized date patient left: Jun 30, 2022, recognized time patient left: 2314." Record review failed to reveal documentation of reassessments prior to departure. Medical record review failed to reveal documentation of risks and benefits of leaving or waiting to be seen by a provider before the patient departed the ED. Review failed to reveal additional visits to the facility for follow up care.

On 07/13/2022 at 0935, a review of the 06/30/2022 waiting room video footage revealed the following: 2054 - Liaison staff sitting at the registration desk, 2056 - female visitor with child (Patient #6) approach registration desk, 2057 - Patient #6 carried by female visitor to the side of the registration desk for vital signs, 2058 - triage nurse walks another patient into the waiting room and takes Patient #6 with a female and male visitor to the triage area, 2106 - male and female visitor carry Patient #6 to the waiting room and sit down, 2312 - female visitor approaches registration desk and hands a cloth object to the Liaison staff, 2313 - male visitor carries Patient #6 through the ED entrance, 2313 - liaison folds cloth and looks at the computer, 2314 - female visitor exits DED entrance.

Interview on 07/13/2022 at 1605 with ED RN #5 revealed he performed the triage for Patient #6. Interview revealed Patient #6 presented with insect bites to the bilateral lower extremities. Interview revealed ED RN #5 did not find signs of systemic reaction like urticarial rash, respiratory distress, swelling tongue, difficulty swallowing secretions when triaging Patient #6. Interview revealed ED RN #5 triaged Patient #6 and placed her in the waiting room with her parents. Interview revealed ED RN #5 did not perform reassessments on Patient #6 while she waited in the waiting room. Interview revealed ED RN #5 was made aware of Patient #6's departure well after they left the facility by the liaison. Interview revealed when patients left after being triaged, the liaison was supposed to get the paperwork completed and document when the patient left.

Interview on 07/13/2022 at 1035 with ED Supervisor #4 revealed she removed Patient #6 from the system on 07/05/2022 because the departure was not documented properly. Interview revealed the ED Supervisor #4 reviewed the liaison comments on the internal communication board to determine when Patient #6 left the DED. Interview revealed the expectation of liaison staff to contact the triage nurse or provider if a patient stated they were leaving the facility. Interview revealed DED staff were educated to encourage patients to stay for examination and treatment. Interview revealed the facility staff only obtained AMA (against medical advice) paperwork for patients that had been seen by a provider. Interview revealed that a patient that had only been triaged would not sign risks and benefits paperwork prior to leaving the facility. Interview revealed a liaison was not able to discuss benefits and risks with a patient leaving after triage or MSE (medical screening exam).

Interview on 07/13/2022 at 1100 with ED Medical Doctor (MD) #6 revealed he was the provider present when Patient #6 presented to the DED. Interview revealed ED MD #6 did not see Patient #6. Interview revealed that triage protocols were available for the triage RN to implement based on their triage assessment. Interview revealed that medications were not administered to patients that were placed in the waiting room because they needed to be monitored. Interview revealed if a patient received Benadryl (antihistamine medication) from the provider or triage nurse, then they would need to be monitored in the back of the DED for potential reactions. Interview revealed DED staff were trained to encourage patients to stay for examination and treatment, if not then explain risks and benefits.

Interview on 07/13/2022 at 1320 with the Interim ED Nurse Director #1 revealed the expectation of DED staff to encourage patients to stay for examination and treatment. Interview revealed the AMA paperwork was only completed for patients that had been seen by the medical providers. Interview revealed patients that had been triaged or were awaiting triage were not asked to sign paperwork acknowledging risks of leaving and benefits of staying in the DED. Interview revealed at the time of Patient #6's DED visit, facility staff were not reassessing patients waiting in the lobby. Interview revealed due to extended wait times, the facility had recently (as of 07/04/2022) implemented hourly rounding and vital signs every two hours on waiting patients. Interview revealed facility staff were expected to document their conversations surrounding left without being seen or against medical advice and the times within the electronic medical record.

Interview request for the liaison on the night of 06/30/2022 revealed she was unavailable for interview.

Interview on 07/14/2022 at 1401 with Liaison #8 revealed that the liaison role was expected to notify the triage nurse or provider whenever a patient expressed that they were going to leave the facility without examination or treatment. Interview revealed the liaisons had been educated to encourage patients to stay and receive care in the DED. Interview revealed only patients that had received an MSE were encouraged to sign AMA paperwork. Interview revealed patients awaiting triage or MSE would not have signed risks and benefits paperwork in their electronic medical record.

Request for census on the night of 06/30/2022 revealed it was unavailable for review.

Review of staffing for the night of 06/30/2022 revealed the following staff: 1 - Charge Nurse, 1 - Triage Nurse, 5 - Staff Nurses, 1 - Liaison, 1 - BH (Behavioral Health) Tech, 1 - ED Tech.