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Based on internal document review, policy and procedures reviews, and interviews, it was determined the facility failed to provide an appropriate medical screening examination 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 exists for 1 out of 20 Sampled Patients (SP). SP#1 (Refer to findings in tag A 2406).

Based on History of patient encounters, Internal document, central log, and policy and procedures review, and interview the facility failed to maintain a central log on each individual who comes to the emergency department, as seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 out of 20 Sampled Patients (SP). SP#1

Findings include:


The facility's Policy titled, "Plan for patient care and performance Improvement" Policy number 700066, review date 01/22, as reviewed. The facility policy revealed in part, "The Emergency Department Log shall be maintained and shall contain, but not limited to the following information relating to the patient: Name, Date, Time and means of arrival, Sex, Record number, Nature of complaint, Disposition, Time of departure ..."
Review of the history of patient encounters dated 02/09/2022 to 02/13/2022 showed no evidence of SP#1's visit to the facility on 02/11/2022. Further review on 04/25/2022 at 10:15 AM revealed there were no records to review for SP#1 and no evidence of the patient's arrival to the Emergency Department (ED) on 2/11/2022.

Review of the facility's internal document revealed SP#1 arrived at the Emergency Room (ER) on 2/11/2022 at approximately 12:20 PM accompanied by a family member. Further review revealed SP#1 was assigned to ER #8 on 2/11/2022, however the facility hadn't yet registered the patient on its central log prior to his elopement at 12:50 PM.

Further review of the facility's internal document revealed "The adolescent walked into the ER voluntarily with his mother and he voiced on several occasions wanting to leave and he didn't want to stay. Mother stated, "no, you have too". The grandmother later arrived and asked to see him, but only one visitor allowed per family. At this time, the mother and grandmother were switching places, when adolescent pushed them both out of the way and ran out of the ER. Adolescent had not been registered or placed in our ER tracker as we were getting ready to register him when it happened."

During an interview conducted on 4/25/2022 at 10:20 AM, the Emergency Room Director stated that SP#1 was in the ER accompanied by a family member. The Emergency Room Director stated that another family member came to switch places with the current family member and when the ED door opened for the exchange, SP#1 fled the ER. The Emergency Room Director also stated the facility is currently documenting persons who enter the facility for emergency services on an Emergency Department Log. Stated this log identifies patient name, arrival date, arrival time and chief complaint.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to maintain a central log for SP#1 on 2/11/2022 when he presented to the ED with his mother seeking medical assistance.

Based on internal document review, policy and procedures reviews, and interviews, it was determined the facility failed to provide an appropriate medical screening examination 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 exists for 1 out of 20 Sampled Patients (SP). SP#1

Findings include:


Review of the facility's internal document revealed SP#1 arrived at the facility's Emergency Room (ER) on 2/11/2022 at approximately 12:20 PM accompanied by a family member.

Further review of the facility's internal document revealed "The adolescent walked into the ER voluntarily with his mother and he voiced on several occasions wanting to leave and he didn't want to stay. Mother stated, "no, you have too". The grandmother later arrived and asked to see him, but only one visitor allowed per family. At this time, the mother and grandmother were switching places, when adolescent pushed them both out of the way and ran out of the ER."

Additional review of the facility's internal document revealed the following statement from the Registered Nurse who was assigned to SP#1, "Patient arrived voluntary status with the mom, we placed the patient in a secluded area away from cables and other potentially harmful equipment. I was assigned the nurse for this patient, I interviewed both the adolescent and the mother. During this time the patient continually verbalized wanting to leave and not wanting to stay, however the mother stated "no you have too". I then told one of our technicians to remain close and assist the mom with anything needed and to watch the door. As the day progressed the unit became busy and the technician was needed to bring samples up to the laboratory for other patients. Moments after this the patient's grandmother arrived to the ER wanting to see him and talk, we allow one visitor/ guardian in with adolescent patients at a time in the ER. So, at this time the mother and grandmother met at the unit's entrance to change places to be with the patient- he then ran towards the door, pushing both the mother and grandmother out of the way before fleeing the emergency room."

Further record review revealed SP#1 was assigned to ER #8 on 2/11/2022, however there is no documentation showing that initial vital signs were taken on the patient and the patient was not triaged by the triage nurse upon arrival. Additionally, the patient did not receive an appropriate medical screening examination which was 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 existed for the patient prior to his elopement at 12:50 PM.

Review of the facility's policy and procedures for Emergency Department Plan and Scope, policy number ER-700-053, review date 01/2022 included, but was not limited to:


To assure that Emergency Medical Evaluation or initial treatment is properly provided by qualified individuals, and appropriate services are provided through a well-defined plan based on patient needs and the defined capability of the hospital.

Departmental Role in Interdisciplinary Cross-Functional Patient Care and Organizational Functions:

1. Patient Rights:
No person shall be refused treatment because of race, creed, sex or ability to pay.

2. Patient Assessment:
All persons seeking care in the Emergency Department will be assessed and triaged and, as indicated, either treated or referred to a more appropriate facility. Evaluation and treatment will be provided, as needed, by the Emergency Department physician or private staff physician. All Patients presenting to the E.D will be offered an Emergency Medical Screening without delay.

Interview with the Emergency Director on 4/24/22 at 10:20 AM, stated that the ED (emergency department) has 8- beds. He/she also stated if the 8-beds are filled, then patients get placed in the hallway. He/she continued to state that when persons enter the facility for emergency services, they ring the bell at the Emergency Department (ED) door. The Emergency Director stated a nurse will answer the door and complete a Patient Demographic Information form. He/she stated this form documents the patient's arrival time and allows the nurse to do a quick assessment related to the chief complaint. He/she stated if there is availability in the ED, the person will be placed on a bed or in a chair and wait to be seen for triage. He/she stated if there is no availability, the nurse will take the person's name and instruct them to wait in the hall. He/she also stated if the patient arrived by ambulance and there is no availability in the ED, the person would need to wait in the ambulance. He/she stated there is a running list of persons who are waiting to be seen. The Emergency Director stated when the person is brought back into the ED, the nurse then begins the registration process and enters the person into the system."

The facility failed to ensure that their Policy and procedure was followed as evidenced by failing to ensure that on 2/11/2022 SP#1 received an appropriate medical screening examination.