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Based on review of video footage, record review and interview, the hospital failed to ensure a person presenting to the emergency department received a medical screening exam (A 2406).

The effect of this deficient practice resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on review of video footage, interview and record review, the hospital failed to ensure a person presenting to the emergency department received a medical screening exam. This affected one (Patient #21) of 21 sampled patients. This had the potential to affect any patient seeking services at the facility.

Findings include:

Review of the security footage, (no audio, video only) revealed on 07/21/19 at 9:14 P.M., a car pulled up to the hospital's satellite emergency department (ED) entrance and Patient #21 got out of the car by himself. The patient marched through the ED automatic doors and appeared to stomp into the ED lobby with arm gestures and sat on a bench inside the facility lobby. Patient #21 moved about, stood up and sat down and switched positions on the bench.

At 9:15 P.M., the sheriff deputy security officer (Deputy #1) placed herself near Patient #21. Patient #21 and the security officer interacted verbally. While they were interacting, a female got out of the vehicle that was at the ED entrance and checked into the ED through the triage desk. While Patient #21 was in the lobby, a staff nurse entered the ED lobby from the ED treatment area and spoke with Deputy #1. The staff nurse returned to the rear of the department through a door that separated the front lobby area from the treatment area.

At 9:19 P.M., two officers arrived to assist the Deputy #1 who had continued to stand near Patient #21 and interact with him. The two officers and Deputy #1 stood near Patient #21 and continued to engage verbally with him. At 9:21 P.M., Patient #21 stood up from the ED lobby bench and walked outside through the ED automatic doors and sat on the bench outside the ED department entrance. Patient #21 never re-entered the ED facility that evening.

At 9:23 P.M., Patient #21 stayed outside with Deputy #1 and his parents joined the group on the exterior of the facility. Patient #21 continued to verbally engage with the officers, but sat on a bench and his gestures diminished. The two officers and Deputy #1 continued to stand near Patient #21 and engage verbally with him.

At 9:30 P.M., a city ambulance arrived at the hospital. At 9:34 P.M., Patient #21 remained outside seated on an exterior bench and engaged with the officers and emergency medical personnel. At 9:37 P.M., Patient #21 stood up and walked to the waiting ambulance with the emergency medical services personnel. The ambulance left the premises with Patient #21 and transferred him to another hospital.

Review of an incident statement written by Staff C revealed she was called to the lobby by registration staff requesting assistance related to an event of Patient #21 "yelling and screaming and hitting self and stating "she did (profanity) heroin"; he was also hitting furniture." Staff C instructed Deputy #1 to try and deescalate Patient #21. Police were called for back-up because Staff C felt that others may be threatened by Patient # 21's behavior and wanted Deputy #1 to have assistance. Staff C requested Deputy #1 "get him off of the property because of his disruption."

Review of Staff C's documentation revealed she was unaware of any request for Patient #21 to be evaluated at the ED, nor did Staff C report she had made any inquiry regarding his visit.

During interview on 09/12/19 at 1:20 P.M., Staff C stated the shift the night of the incident was very busy. Staff C described the set up in the ED as a front area where registration, triage and the lobby open to the public, and there was a back area where the medical, nursing staff, and patient treatment beds were located that was a distinct part from the front. The persons in the back cannot hear what is happening in the front area, so staff in the front have to call the back area by phone. There was a flat screen monitor on the nursing desk in the back section where the front lobby, entry and parking lot could be viewed and video was recorded.

Staff C stated she learned there was an issue in the front lobby because a registration staff person called her on the phone and then she walked to the front lobby. In the front lobby Staff C observed Patient #21 seated on lobby furniture cursing and being disruptive with Deputy #1 near him. Staff C said Patient #21 was known to the hospital from prior visits. Staff C said she called for additional police because she did not think Deputy #1 was going to be able to deescalate Patient #21 by herself.

Staff C stated she walked to Deputy #1 and Patient #21 and requested Patient #21 be removed from the lobby as his actions were creating a disruption and potentially intimidating other patients. Staff C said she was not aware if Patient #21 wanted to be evaluated, nor did she inquire about his reason for being at the facility. Staff C did not speak with Patient #21's parents, who had arrived at the hospital with him.

During interview on 09/13/19 at 11:32 A.M., Staff E stated she worked in registration at the front desk of the emergency department during this incident. She recalled she was registering another patient when Patient #21's mother walked into the ED entry and asked the other registrar for help. Patient #21's mother said she wanted to admit Patient #21 and his female companion "because of relapse." The admissions staff person said Patient #21 had been loud, yelling, cursing, but expressing anger at himself because he had just gotten out of rehabilitation for drug use. Staff E said Deputy #1 immediately stood near Patient #21 and engaged him verbally. Staff E observed Staff C enter the front lobby from the back secured area and tell Deputy #1 to get Patient #21 out of the lobby. Eventually, Patient #21, Deputy #1 and two additional police walked outside to an area adjacent to the ED entrance.

Staff E said Patient #21's mother expressed an interest in getting treatment for him and Patient #21's father was upset because Patient #21 was being asked to leave. He verbalized the intent of their visit was to get help for Patient #21. Staff E observed Patient #21 was repetitively expressing anger at his apparent relapse and verbally expressed a desire to get help. When the group had moved outside, Staff E stepped out to speak with Patient #21's parents who expressed concern about why Patient #21 was being sent somewhere else. Staff E said Patient #21 had calmed down while outside, but she did not ask him any questions, and did not ask him if he wanted to sign in for treatment. Staff E was aware of Staff C's request to have Patient #21 removed from the lobby of the hospital.

Review of Patient #21's medical record from the receiving hospital revealed he was admitted to the emergency department on 07/21/19 at 9:49 P.M. with a chief complaint of overdose- accidental, chest pain and altered mental status. Patient #21's treatment included a urine screen, X-ray of right hand and chest, a CT scan of his head, a 12-lead electrocardiogram, a blood screen for drugs, and an opioid referral related to chemical dependency. Patient #21 had medical diagnoses including coronary artery disease, high blood pressure, anxiety hyper-activity disorder (ADHD), bipolar disorder, post-traumatic stress disorder (PTSD) and seizures.

Review of the emergency room documentation revealed after consent was obtained to discuss his condition with his parents Patient #21's father reported the patient had been released from addiction treatment the day prior and was found after using heroin. Patient #21's father reported the patient was agitated, hitting his head on the wall and punching the wall. His parents had taken him to the transferring ED for further evaluation.

Review of the nursing notes revealed Patient #21's father reported the patient had a history of heroin and prescription medication abuse and previous overdoses. Review of the documentation revealed Patient #21 admitted that he had snorted heroin and Fentanyl prior to this episode and had a history of using other illegal drugs. Patient #21 complained of constant, sharp, left-sided chest pain and right hand injury/ swelling. Review of his vital signs revealed he had a fast heart rate. At the emergency room Patient #21 received supplemental oxygen and intravenous Narcan (opioid reversal medication) due to admitted heroin use and diminished mental status consistent with overdose, Versed (anti-anxiety medication) for agitation, and one liter of intravenous fluid for hydration because blood work showed acute kidney injury. Patient #21 was discharged on 07/22/19 in the morning hours.


This citation substantiated complaint OH00106089.