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Based on staff interview and document review, it was determined the facility failed to provide an appropriate medical screening exam (MSE) to determine whether an emergency medical condition (EMC) existed in one of twenty records reviewed in the survey sample (Patient 4 [P4]).

Cross Reference:

CFR(s): 489.24(a) & 489.24(c) Medical Screening Exam

Based on staff interview and document review, it was determined the facility failed to provide an appropriate MSE to determine whether an EMC existed in one of twenty records reviewed in the survey sample (P4).

Findings:

Review of the facility policy titled "EMTALA - Compliance with the Emergency Medical Treatment and Labor Act" dated December 2021, revealed "Any individual who comes to an Inova Dedicated Emergency Department, requesting, or for whom a request is made, examination or treatment for a medical condition, shall be given an appropriate medical screening." The policy defines an EMC as "A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that in the absence of immediate medical attention could reasonably be expected to result in (i) placing the health of the individual ... in serious jeopardy ..."

Review of the facility procedure titled "IHS Administrative Discharge Due to Disruptive Behaviors Procedure" dated April 2023, algorithm revealed "If appropriate Team Member counsels individual to clarify expectations and seeks to understand reason for behavior. Notify immediate supervisor (RNUS, CD, MD). Step 1: Clinical Director will assess and address the disruptive behavior for why to include underlying medical condition, environmental triggers, special needs."

Review of nursing documentation for P4 dated September 12, 2023, at 3:13 PM revealed "Patients [sic] to the ED via EMS (Emergency Medical Services) stretcher from home with c/o (complaint of) hyperglycemia (high blood sugar) and generalized body pain, patient is writhing on the EMS stretcher, leapt from EMS stretcher to the ED stretcher and continued to yell demanding IV (intravenous) fluids."

Review of nursing documentation for P4 dated September 12, 2023, at 3:14 PM indicated the patient was "uncooperative" and swung at the nurse. The nurse documented leaving the room "explaining aggressive behavior would not be tolerated" at which time the patient "eloped."
There was no indication that nurse reported behavioral concerns to the immediate supervisor in the documentation.

Interview with Staff Member (SM) 5, nurse, on October 30, 2023, at 2:00 PM revealed "the patient was in obvious pain and writhing on the stretcher" and that the patient was repeatedly shouting "I am in DKA (diabetic ketoacidosis) and need IV fluids." The American Diabetes Association indicates that DKA occurs in people who have diabetes and do not have enough insulin to utilize glucose for energy resulting in the body breaking down fat to create energy, overloading the bloodstream with ketones; DKA is dangerous and can result in coma and even death.

Interview with SM4, Emergency Department Director, on October 30, 2023, at 2:06 PM revealed that the facility process for managing aggressive patients is to "attempt to deescalate violent behavior ..."