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Based on hospital document review, policy review, medical record review, law enforcement document review, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical attention were provided an appropriate and ongoing Medical Screening Examination (MSE) for 1 of 20 (Patient #4) sampled patients reviewed.

The findings included:

Medical record review revealed Patient #4 was taken to the ED via law enforcement on 9/4/2025 after the Patient was taken from a local residence where she was yelling, uncooperative and had reportedly bitten a family member. The Patient arrived at the ED at 6:12 PM and was escorted by law enforcement to a room deemed safe for psychiatric patients, where Registered Nurse (RN) #1 attempted to complete a triage assessment. Patient #4 was uncooperative with the RN, belligerent, and became combative and verbally aggressive when the RN attempted to obtain vital signs and remove the Patient's clothing and belongings to put the Patient in a hospital gown. The RN was unsuccessful in completing the triage assessment for Patient #4, but was assigned an Emergency Severity Index (ESI - a tool for prioritizing patients in the emergency department) level 2, emergent (the patient is high-risk or has a potentially life-threatening condition). There was no documentation a MSE was completed by ED Provider #1 to determine if an Emergency Medical Condition existed for Patient #4. The RN documented Patient #4 struck her on her arm, and law enforcement personnel arrested the Patient and escorted the Patient back to jail at 6:53 PM. Patient #4 remained in jail until 9/6/2025 when she was transported by law enforcement to Hospital #2, an inpatient psychiatric hospital, where she was involuntarily admitted.

Cross Refer to A-2406.

Based on hospital document review, policy review, medical record review, law enforcement document review, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical attention were provided an appropriate and ongoing Medical Screening Examination (MSE) for 1 of 20 (Patient #4) sampled patients reviewed.

The findings included:

Review of the hospital's "Medical Staff Bylaws" dated 1/2/2025 revealed, "...Each member of the Medical Staff shall...Provide his/her patients with continuous care at the generally recognized professional level of quality...Abide by the Medical Staff Bylaws and other lawful standards, policies and Rules and Regulations of the Medical Staff...Appendix "B" - Rules & Regulations... Emergency Medical Screening, Treatment, Transfer...Screening (1) Any individual who presents to the Emergency Department of this Hospital for care shall be provided with a medical screening examination to determine whether that individual is experience an emergency medical condition. Generally, an "emergency medical condition" is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child...All patients shall be examined by qualified medical personnel, which shall be defined as a physician...Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge..."

Review of the hospital's "Entry into ED Process, 780-1002" policy effective 4/2025 revealed, "Purpose To describe the two-tiered system of the triage and medical screening process which is an organized systematic method of assessment and prioritization of patient care needs ensuring immediate care of the acute patient...Triage is a sorting process to determine the order in which patients will be provided a medical screening examination by a physician or qualified medical person. Triage is not the equivalent of a medical screening examination and does not determine the presence or absence of an emergency medical condition. Using the Emergency Severity Index (ESI), which is a five level tool to rate patient acuity, the triage nurse will rate the patient's acuity from level 1 (most urgent) to level 5 (least resource intensive)...Level 1: Requires immediate response (e.g. cardiac arrest) Level 2: Treatment to commence within ten minutes (e.g. airway risk) Level 3: Treatment to commence within 30 minutes (e.g. hypertension)...Triage directs patients to treatment areas within the department most appropriate for their needs...Medical Screening Exam is process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists...Such screening must be done within the facility's capability and available personnel, including on-call physicians. The medical screening exam is an ongoing process and the medical record must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred/discharged...All patients will be triaged upon arrival to the ED...Patients with emergency medical condition (category I or II) will be placed in an available treatment area for immediate initiation of the medical screening exam...[Named hospital] will perform the Medical Screening Exam (MSE) to determine if an emergency medical condition exists...The MSE must be the same MSE that the hospital would perform on any individual coming to the hospital's emergency department with those signs and symptoms...A MSE is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred/discharged. There should be evidence of this evaluation document in the medical record prior to disposition...The patient will be treated according to physician's orders and/or protocols which will be written on the ED record...Those patients with emergency conditions are treated immediately according to protocols and/or as required by the ED physician. Those patients who need consultation by specialty physicians and/or services for stabilization will have specialty care rendered within the capability of this facility..."

Review of the hospital's "Copy of LL.026 EMTALA [Emergency Medical Treatment and Active Labor Act]- Medical Screening and Treatment of Emergency Medical Conditions" policy effective 9/2023 revealed, "...Purpose: To ensure that individuals coming to an affiliated Hospital's Dedicated Emergency Department [DED] seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act ("EMTALA")... and, if an Emergency Medical Condition is determined to exist, such individuals are offered stabilization treatment within the capabilities and/or are transferred if appropriate...Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (inkling severe pain, psychiatric disturbances and/or symptoms of substance about) such that the absence of immediate medical attention could reasonably by expected to result in...Placing the health of the individual...in serious jeopardy...Serious impairment to bodily functions; or...Serious dysfunction of any bodily organ or part...Medical Screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor...The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred. Triage does not constitute a Medical Screening Examination...Policy: Any individual who comes to the Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exists. If an Emergency Medical Condition is found to exist, the Hospital will...provide (a) stabilizing treatment within the capabilities of the hospital and its staff...and/or (b) an appropriate transfer to another medical facility...The Hospital should utilize the Triage Process to determine the order in which patients receive a Medical Screening examination and further treatment as necessary. Triage does not determine the presence or absence of an Emergency Medical Condition...In general, when an individual...comes to a Dedicated Emergency Department and requests assessment or treatment for a medical condition (whether or not the individual believes it to be an emergency), or the request is made on the individual's behalf...The Hospital must provide for an appropriate Medical Screening Examination conducted by a physician or other Qualified Medical Professional...If the Medical Screening Examination reveals an Emergency Medical Condition, then the Hospital must provide stabilizing treatment within its capacity and capabilities...necessary to stabilize the patient or must appropriately transfer the patient to another facility..."

Review of the hospital's "Potentially Violent Individuals (Code Violet), 835-1063" policy approved 6/2025 revealed, "...The purpose of this policy is to outline the necessary steps to take when dealing with a patient, visitor, co-worker or any other person who is showing signs of violence and/or aggressive behavior...Security and/or all able bodied "Handle with Care" - trained staff male employees shall respond to the area. Security and/or "handle with Care"-trained staff members shall respond and along with nursing, take control of the situation. 4. If the subject refuses to calm down and the potential for physical injury is possible the response team may restrain the individual in order to reduce or eliminate the threat to the subject, our staff and other patients..."

Review of the hospital's ED Log revealed Patient #4 was taken to the ED via law enforcement on 9/4/2025 at 6:11 PM with chief complaint of "Psych Problem."

Medical record review revealed Patient #4 arrived in the ED at 6:12 PM. ED Provider #1's physician's order revealed, "18:14 [6:14 PM] MSE Initiated by Provider...Dispensed Medications...18:23 [6:23 PM] CANCELED (Other): ziprasidone IM [intramuscular] 20 mg [milligrams] IM once..."

Review of a note written by RN #1 revealed, "Presentation: 09/04 [2025] 18:13 [6:13 PM] Acuity: Emergent (2) [the patient is at high-risk of a potentially life-threatening condition]. 18:24 [6:24 PM] Presenting complaint...Pt [patient] came in by [local law enforcement]. Pt was belligerent on arrival unable to calm or redirect. Pt was aggressive was threatening to "punch the nurses here." Pt was yelling and screaming at me to not touch her, states I did not have consent to touch her. Pt states she refuses to undress "in front of this bisexual bitch." Pt screaming for head nurse, states she is going to punch staff here. Unable to calm patient, refusing for vitals to be taken. Placed BP cuff on pts arm she removed it. Pt did punch me, hit left forearm. [local law enforcement] at bedside as well as hospital security. Pt was escorted to jail by [local law enforcement]. [Named law enforcement officer] escorted pt to cop car all belongings were sent with pt. Pt screaming during entire stay unable to calm...Vital Signs...18:24 [6:24 PM] unable to obtain...18:37 [6:37 PM] Discharged to police custody. Pt taken to jail by law enforcement, no instruction given to pt...18:53 [6:53 PM] Patient left the ED...Disposition Summary...Left Against Medical Advice...Condition: Unknown..."

Review of an addendum written by ED Provider #1 on 9/20/2025 at 7:28 AM revealed, "This patient left before evaluation. No provider encounter..."

There was no documentation a MSE was completed to determine if an Emergency Medical Condition existed, no documentation the Patient's condition was stabilized, and no documentation to indicate the Patient's condition when Patient #4 left the hospital.

Review of the police report narrative dated 9/4/2025 revealed officers were dispatched to perform a welfare check in the community. "Upon arrival...There were 2 females standing and 1 was sitting on the ground. The 2 standing...stated that the female on the ground [Patient #4] was having a manic episode. [Patient #4] was yelling for people to leave her alone and that people were attacking her. She was visibly shaken and crying frantically..." The officers informed Patient #4 they were taking her to the ED and allowed her to gather some of her belongings to take with her. The report indicated the 2 females that were standing were the Patient's mother and sister and Patient #4's mother had recently picked the Patient up from a group home out of town and brought her to her home. The report revealed, Patient #4's mother informed the officer, "Since that time [Patient back from out of town], as long as [Patient #4] was taking her medication, there were no issues. But recently [Patient #4's mother] believes that [Patient #4] was either refusing to take her meds or had run out, the result was what we were currently witnessing..." The report indicated Patient #4 "was originally very against the transport...After some coaxing...she did agree to go..." The report indicated the Patient was transported to the ED by 2 of the officers that were onsite, and Law Enforcement Officer #1 stayed behind at the residence and was informed Patient #4 had bitten her sister when they "were attempting to hold her down ([Patient #4] wanted to drive off)...I [Law Enforcement Officer #1] left the residence and headed to the ER [Emergency Room]...Once I arrived I opened the doors to the ER and heard a lot of screaming and yelling coming from room 5 [ED room considered a safe room for psychiatric patients]. As I approached [named law enforcement officer] said that [Patient #4] was being very uncooperative with the nurses and security. She was refusing to let the nurses put her in a gown stating that "all women in [named town where Hospital #1 was located] were Bi-sexual" and she didn't feel comfortable undressing in front of them. This banter went back and forth for a few seconds, before I decided to tell her that if she continued to act out, I would simply take her to jail. This statement worked for roughly a minute before she became irate and struck a nurse with a closed fist on the nurse's right arm. At this point I [Law Enforcement Officer #1] decided to place [Patient #4] in custody for assault and transported her to jail. While at jail she did verbally resist the jailers numerous times, and was placed in the observation cell. I did contact mobile crisis and advised them of the situation. They stated they would respond back in less than 2 hours with a counselor. At no point was force used against [Patient #4] by [named local law enforcement] deputies, she was compliant with verbal commands."

During a telephone interview on 9/23/2025 at 10:20 AM, RN #1 verified she recalled Patient #4. The RN stated the Patient was brought into the ED by local law enforcement. The RN stated she was explaining she had to remove the Patient's belongings and clothes, put her in a gown and check her vital signs, the Patient "absolutely refused everything. I told her I have to take her belongings and put her in a gown and explained I had to make sure she was safe. She ripped everything off I put on her [blood pressure cuff]. I couldn't calm her down. I was genuinely afraid she was going to hurt me; I was trying so hard to help her. It was unsafe for myself, herself, and us; they [law enforcement] took her back to jail." RN #1 was asked if ED Provider #1 assessed the Patient. The RN stated, "I don't remember." RN #1 was asked if there was any indication Patient #4 was acutely psychotic or intoxicated. The RN stated, "not intoxicated or under the influence. She was just so riled up I couldn't do a true assessment."

During a telephone interview on 9/23/2025 at 1:35 PM, ED Provider #2 verified he was the ED Medical Director. The ED Provider was asked how ED Provider #1 determined the Patient was not acutely psychotic or experiencing an emergency medical condition. The Provider stated, "I can't answer that. I wasn't there and didn't witness it. Typically, the evaluation happens concurrently when the patient arrives. I was told when the Patient arrived, police were involved." ED Provider #2 continued and stated Patient #4's condition deteriorated to a violent encounter, so it became a "legal matter, not a medical matter."

During a telephone interview on 9/23/2025 at 2:47 PM, ED Provider #1 stated Patient #4 "didn't want to be seen and she was rude." ED Provider #1 was asked if he assessed Patient #4. The ED Provider stated, "Unfortunately no. The nurse [RN #1] was with her and when I got ready to see her, she was gone. She didn't want to be seen and was very rude." ED Provider #1 was asked why he documented he initiated the MSE at 6:14 PM. The ED Provider stated, "I clicked it [initiated the MSE] because the Patient is in the ED, it doesn't mean I've seen the Patient." ED Provider #1 was asked if Patient #4 had a psychiatric or emergency medical condition. The Provider stated, "I don't know, but she had a psychiatric history." The ED Provider was asked why he ordered ziprasidone for the Patient since he hadn't evaluated her. ED Provider #1 stated, "We usually give patients something to help calm them down." The ED Provider stated he had written an addendum (9/20/2025; 15 days after Patient #4 presented to the ED) stating he never saw the Patient. ED Provider #1 continued and stated, "I don't know how they let her go; that was a problem."

During an interview on 9/23/2025 at 3:00 PM, the hospital's Director of Quality and Risk Management (DQRM) stated she had spoken with local law enforcement, and they informed her mobile crisis evaluated Patient #4 at the jail and the Patient was taken to Hospital #2, a psychiatric facility, for inpatient treatment, then was sent back to jail after she was discharged. The DQRM stated the hospital had met with law enforcement personnel and informed them they don't have to send everyone to the ED. The DQRM continued and stated the hospital was "working with them on that. We or they can call mobile crisis who then refers them to [Hospital #2] for evaluation and treatment."

During a telephone interview on 9/24/2025 at 3:02 PM when the surveyor attempted to reach Law Enforcement Officer #1, the phone call was accidentally routed to RN #2 instead. The RN informed this surveyor she recalled Patient #4 was taken to Hospital #1's ED and "when they tried to remove her clothes, she swung at one of the nurses so they [ED staff] sent her back here. When I talked to her [Patient #4] she told me she has a fear of being raped, so she felt threatened when they tried to remove her clothes. After she got back with us, we called mobile crisis. They [mobile crisis] evaluated her, and she was taken to [Hospital #2] and admitted." RN #2 continued and stated law enforcement personnel now "have to call mobile crisis because the hospital won't treat for mental illness or mental crisis. We've had meetings with hospital staff and some of the higher ups. They've told us to just call mobile crisis because that's all they're going to do anyway. I used to send patients that were on suicide watch to them after they bonded out to make sure they were safe to go home. We were told not to do that anymore because the only thing they're going to do is call mobile crisis and we can do that here." RN #2 stated Patient #4 informed her she swung at one of the nurses [RN#1] when she tried to remove her clothes so the ED "called to have her arrested. They [Hospital #1] can't handle anybody that gets combative because they don't have enough security for that."

During a telephone interview on 9/25/2025 at 8:31 AM, Security Officer (SO) #1 verified he was present in the ED when local law enforcement brought Patient #4 in. The SO stated Patient #4 was "somewhat combative and upset. Me and the nurse [RN #1] went in to get the Patient's blood and urine and she was yelling, and she hit the nurse in the arm and was going to hit her again, but I stepped in between them. The [law enforcement officer] was standing outside the door. She was getting louder so the [law enforcement officer] decided he was going to take her to jail." The SO was asked if the law enforcement officer was present in the room during the alleged altercation. The SO stated, "the only time he [law enforcement officer] came into the room was when he decided to take her to jail. He gave me the handcuffs, so I handcuffed the Patient and escorted her out to the police car." The SO was asked if the (ED staff) requested the law enforcement officer's assistance with Patient #4. The SO stated, "No, I stepped in." The SO was asked if ED Provider #1 ever saw Patient #4. The SO stated, "I don't think so, the whole thing only lasted about 4 or 5 minutes."

Patient #4's medical record from Hospital #2 revealed the Patient was involuntarily admitted on 9/6/2025 from jail with diagnoses which included Unspecified Schizophrenia Spectrum and Other Psychotic Disorder and Unspecified Mood (Affective) Disorder. The Psychiatric Evaluation completed on 9/6/2025 revealed Patient #4 was in a manic state, delusional, aggressive, hyperverbal, with rambling speech, uncooperative and had allegedly assaulted a nurse at the ED and was subsequently sent to jail. The evaluation revealed, "multiple attempts at conducting a comprehensive interview were met with resistance, bizarre behavior and delusional themes..." Patient #4 was considered at risk for elopement and violent behaviors.

Hospital #1 failed to complete a Medical Screening Examination to determine if Patient #4 had an emergency medical and/or psychiatric condition. The hospital's failure to complete a Medical Screening Examination resulted in a delay of treatment for Patient #4 who spent 2 days in jail in a manic state and psychosis while awaiting assessment and stabilizing treatment.