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Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings included:

The hospital failed to ensure a thorough medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 29 sampled patients (Patients #4, #5).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406 cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

Based on policy and procedure review, medical record review and staff and physician interviews, the hospital failed to ensure a thorough medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 29 sampled patients (Patients #4, #5).

The findings include:

Review of the EMTALA policy, dated 02/2020, revealed "...Emergency services and care, including an appropriate Medical Screening Examination, will be provided to individuals who 'come to the emergency department' and request examination or treatment of a medical condition....A Medical Screening Examination will be done to determine if an Emergency Medical Condition exists. ..."

Review of the Policy "REFUSAL TO SUBMIT TO TREATMENT", dated 09/19, revealed "...When a competent patient refuses necessary medical treatment or desires to leave the facility against medical advice, they will sign the release form entitled Refusal to Submit to Treatment. ..."

DED Medical Record review revealed Patient #5 returned to the DED on 11/30/2021 at 1808. Review of "ED Physician Documentation", signed 11/30/2021 at 1823, revealed " ...I was called by nursing staff to code stroke assessment area at approximately 1815. On my history, patient reports a sensation of 'dizziness' for the last several days since this past Friday. He describes an intermittent feeling of 'feeling like I am falling over to my left'. He describes trying to write something on paper and 'my hands not writing the right words'. He denies any new symptoms over the last 4.5 hours. On my exam, patient has 5/5 strength in all major motor groups of all 4 extremities. Sensation intact to light touch in all 4 extremities. Cranial nerves II through XII fully intact with no evidence of facial droop, dysarthria or aphasia. On my assessment, patient is fang D (Field cut, aphasia, neglect, gaze preference, and dense hemiparesis- part of a stroke screen) negative and does not meet criteria for code stroke activation at this time. I do feel he is appropriate for return to triage area for likely additional diagnostic testing during this ED visit. ***No indication for Code Stroke activation at this time. ..." Further DED record review revealed at 2306 (~5 hours after arrival) a "Hand OFF Communication - Transport" Note that stated "pt left without being seen, IV removed in triage." Review of a Neurological Assessment recorded at 2307 revealed " ...Neurological Symptoms ....Dizziness. ..." Further review of "ED Physician Documentation", no time performed noted, and electronically signed 12/09/2022 at 0629 revealed "Patient was outside the window for TPA or endovascular therapies and thus not a candidate for CODE STROKE upon arrival to triage. While awaiting further work-up for his symptoms, patient eloped from the emergency department waiting room prior to any diagnostic testing being able to be performed." Review of the DED medical record did not reveal an AMA form signed in the record, did not reveal any documentation that Patient #5 refused to sign, and did not reveal any notation of talking with Patient #5 and explaining the risks of leaving.

Telephone interview on 09/01/2022 at 0915 with MD #2, the physician who saw Patient #5 on the 11/30/2021 visit revealed MD #2 did not recall Patient #5 but had access to the record. Interview revealed the facility/physician did a rapid assessment for "Code Stroke" when there was a possibility of TPA (tissue plasminogen activator-clot buster treatment for stroke) or thrombectomy (surgical removal of a blood clot). Interview revealed the symptoms had to have been present less than 24 hours, and for TPA less than 4 ½ hours. Interview revealed with Patient #5 onset of symptoms were on Friday, the patient's strength was good and there were no sensory deficits. Interview revealed Patient #5 was not a candidate for TPA or thrombectomy and so it was appropriate to have him go through the normal triage process after the Code Stroke screening was completed. MD #2 stated the work-up was still important and Patient #5 "100%" needed admission for a full stroke work up, including echocardiogram, carotid doppler and either CT or CT angiogram. Interview revealed MD #2 was not aware when the patient left the ED and did not know/ recall hearing of anyone saying he wanted to leave or going over the risks of leaving but noted there were several providers in the ED at the same time and MD #2 was not sure if another provider was informed.

Telephone interview with RN #4, the RN who documented Patient #5 left without being seen and that the IV was removed in triage, revealed RN #4 did not recall Patient #5 or the situation". Interview revealed in general RN #4 would encourage patients to stay and stated she might get a physician to see the patient. RN #4 stated it looked like a documentation issue but did not recall. Further interview revealed a situation like this would "typically prompt an AMA (Against Medical Advice)", including a conversation with the Charge Nurse and Doctor.

Telephone interview with RN #5, the Triage RN for Patient #5, revealed the RN had no memory of the patient or the situation, stating there was a surge of patients in November 2021. Interview revealed that as Triage Nurse, RN #5 told patients to come up to them with any worsening symptoms. Interview revealed if she knew the patient was leaving, RN #5 would try to talk with patient into staying but if they did not stay she would notify the physician and get the patient's IV out. Interview revealed she generally would try and get the AMA form and if the patient would not sign, would document that in the medical record.

Review of "ED Physician Documentation", time seen 12/01/2021 at 1952, revealed Patient #5's chief complaint was "pt reports that he got an outpatient CT done here and stated that it showed he had a stroke.... TBA (to be admitted) per PCP (Primary Care Provider). ..." Physician Documentation further revealed " ...History of Present Illness 67-year-old male, who presents for roughly 5 days of gait ataxia, left upper extremity weakness, unable to write, intermittent slurred speech, and vertigo. Said the symptoms began on 26 November with right-sided ear ringing, nausea, profuse vomiting. He went to sleep. Next day followed up at the ED at that time his symptoms seem to be intermittent, symptoms improved after IV fluids and antiemetics in the emergency department was discharged home. He was seen last night in our emergency department however left without being seen unfortunately and today had a CT scan of his brain that showed a posterior ....stroke likely subacute consistent with his history of symptoms beginning on 11/26/2021.... Do feel he requires admission for completion of stroke work-up, evaluation by PT (Physical Therapy) OT (Occupational Therapy). Discussed case with hospitalist who agreed for admission .... Assessment/ Plan 1. Cerebellar Stroke. ..." Review revealed Patient #5 discharged 12/04/2021.

2. DED medical record review revealed Patient #4 arrived to the Emergency Department by EMS. Review of the "Emergency Department Provider Note", date of service 04/24/2022 at 0302, revealed "Chief Complaint ...Assault Victim ....BIB (brought in by) EMS (Emergency Medical Services - ambulance) for assault pt was found down in a parking lot, pt is responsive to painful stimuli answer questions, dried blood noted to nose hematoma to front and back of head. Pt has been drinking EMS estimates incident happened around 0045 ....Alcohol Intoxication ....24 y.o. (year old) male unknown medical history presents today ...after alleged assault.... He was found laying on the ground unresponsive. He had reportedly been drinking heavily. Patient was only verbal to noxious stimuli, monitoring, but not following any commands. Vital signs were normal. Has evidence of trauma to the face with dried blood mostly in a hematoma over the left forehead .... moves all extremities but does not follow commands...Musculoskeletal: No long bone deformities Neurologic: Slurred speech minimally responsive, will say name when asked with noxious stimuli Skin: Hematoma left forehead. ..." CT exams were done of the Abdoment/Pelvis, Chest, Lumbar Spine, Thoracic Spine, and Cervical Spine were completed with no fractures. A CT of Facial Bones without Contrast, electronically verified at 0417, revealed "Acute bilateral nasal bone fractures. Moderate left frontal scalp left periorbital hematoma". Further review of the ED Provider Note revealed " ...ED Course and Medical Decision Making .... Reassessment: ED Course .... Sun Apr 24, 2022 0833 I assumed care of this patient from previous provider....I discussed results of his imaging and recommended follow-up with ENT as needed outpatient. Patient awake, talking, and appears to be clinically sober at this time ....Clinical Impressions .... Alcohol intoxication delirium ....Traumatic hematoma of forehead, initial encounter Fracture of nasal bones, initial encounter for closed fracture .... CT scan shows evidence of nasal bone fracture, no active bleeding no evidence of septal hematoma, breathing well without abnormality, no other significant findings other than forehead hematoma ....Plan for sober reevaluation for discharge home. ..." "ED Care Timeline" review revealed " ...08:55 .... Departure Condition ....Good Mobility at Departure : Ambulatory Patient Teaching: Discharge instructions reviewed Departure Mode: By self .... 09:00 ....Peripheral IV ....Removed ....09:10 .... Patient discharged ...." DED medical record review did not reveal any numerical pain scales and did not reveal notation of patient comfort after 0730 when the patient was noted to be sleeping/ resting comfortably. Review did not reveal any evidence of x-rays of arms or legs and did not reveal evidence of physical examination after the patient was clinically sober to evaluate for additional injuries/concerns the patient may have identified including injuries or pain in the arms or legs.

Telephone interview on 08/31/2022 around 1500 revealed MD #6 did not recall Patient #4. Interview revealed in that case of significant trauma, they did a "pan CT", basically did a CT of everything. In regards to arms and legs, MD #6 stated if a limb was "deformed or mangled" they would definitely x-ray but if not, they relied on the exam and reexamination. At the time of the initial MSE, the patient was not sober enough to participate. In this case, MD #6 stated, he handed the patient off to the oncoming physician to complete the exam. Interview revealed MD #6 did not recall Patient #4 complaining of any pain in his extremities.

Telephone interview with MD #7, the physician who took over the care of Patient #4, on 08/31/2022 at 1535, revealed he recalled Patient #4. Interview revealed he briefly signed on to the patient around 6:00 am. The patient, he stated, had been scanned from head to toe and had a nasal bone fracture. Interview revealed they allowed the alcohol to metabolize and then the patient could leave. Patient #4 was there a couple of hours, awake and talking. MD #7 stated he always sat down and went over the plan with patients and made sure patients could stand and walk prior to discharging them. Interview revealed Patient #4 never mentioned anything about his arm to MD #7. Interview revealed he did not recall touching or doing a physical examination of the patient's arms but he generally asked patients about questions or concerns. Interview revealed Patient #4 was clinically clear and able to make decisions, was able to stand and ambulate and was stable for discharge. Interview revealed the patient received prescriptions for naproxen and Tylenol for pain, that MD #7 wanted to be sure he was comfortable when sending him home.

Interview with RN #9, on 08/31/2022 at 1450, revealed the RN remembered the situation but did not recall much about the patient. Interview revealed RN #9 did not see a pain assessment at discharge. Further interview revealed RN #9 did not recall anything related to Patient #4's arms.