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Based on review of medical records, policy and procedures, video recording, and staff interviews it was determined that the facility failed to conduct an appropriate medical screening examination to rule out an emergency medical condition and ensure that the risks and benefits of continued treatment was reviewed with the patient and documented in the medical record for one (P#1) of 20 sampled patients. Specifically, P#1 arrived at the facility via ambulance on 5/20/25 at 11:00 p.m. for a mental health examination and headaches. A medical screening examination was initiated 5/21/25 at 12:21 a.m. Local law enforcement was called to escort P#1 from the property after staff reported that P#1 refused treatment and was disruptive in the lobby. An attempt to obtain a signed refusal of care or against medical advice, including the risks and benefits of treatment was not obtained. P#1 was discharged AMA at 3:27 a.m. on 5/21/25 accompanied by local law enforcement.

Findings included:

Cross refer to A2406 as it relates to the facility's failure to ensure that the risks and benefits were explained to a patient prior to being discharged against medical advice.

Based on review of medical records, policy and procedures, video recording, and staff interviews it was determined that the facility failed to conduct an appropriate medical screening examination to rule out an emergency medical condition and ensure that the risks and benefits of continued treatment was reviewed with the patient and documented in the medical record for one (P#1) of 20 sampled patients. Specifically, P#1 arrived at the facility via ambulance on 5/20/25 at 11:00 p.m. for a mental health examination and headaches. A medical screening examination was initiated 5/21/25 at 12:21 a.m. Local law enforcement was called to escort P#1 from the property after staff reported that P#1 refused treatment and was disruptive in the lobby. An attempt to obtain a signed refusal of care or against medical advice, including the risks and benefits of treatment was not obtained. P#1 was discharged AMA at 3:27 a.m. on 5/21/25 accompanied by local law enforcement.

Findings:

A review of Patient (P) #1's medical record revealed that she arrived at the facility via Emergency Medical Services (EMS) on 5/20/25 at 11:00 p.m. with chief complaint of mental health evaluation and headaches. A review of the nursing triage note dated 5/20/25 at 11:10 p.m. revealed that P#1 requested admission to an inpatient psychiatric facility. Continued review of nursing note dated 5/20/25 at 11:40 p.m. revealed that P#1 refused to have vital signs taken and was yelling in the lobby. At 11:53 p.m. facility staff spoke with P#1 about her yelling and disruptive behavior in lobby. Staff was unable to de-escalate. Security was called to speak with P#1. P#1 was observed spilling food and belongings in the ED lobby. P#1 agreed to have vital signs taken.

Review of physician medical screening note dated 5/21/25 at 12:21 a.m. revealed that P#1 presented with a headache and MHE (mental health exam). MSE was initiated and diagnostic testing was ordered.

Continued review of a nursing note dated 5/21/25 at 1:15 a.m. revealed that P#1 tolerated medication given. A review of the ED Flowsheets dated 5/21/25 at 1:14 a.m. failed to reveal any documentation of observed behaviors.

A nursing note dated 5/21/25 at 2:28 a.m. revealed that radiology staff attempted several times to take P#1 to radiology. P#1 shouted at the radiology technician that 'I am sleeping, get out of my face'. Staff attempted to redirect P#1. P#1 observed pacing in the lobby and shouting. Security staff attempting to de-escalate P#1. Continued review of nursing note dated 5/21/25 at 2:36 a.m. revealed that P#1 refused vital signs and security staff continued to speak with her. ED provider notified, who stated that P#1 could leave AMA (against medical advice) if she continued to refuse treatment.

A nursing note dated 5/21/25 at 3:19 a.m. revealed that PAS (patient access services) attempted to register P#1. P#1 shouted at PAS clerk that she was sleeping. Continued review of nursing note dated 5/21/25 at 3:24 a.m. revealed that P#1 paced the lobby and was shouting. Security staff redirected P#1 to sit in a chair. P#1 sat in a chair and laid on another patient in the seat next to her. P#1 began to scatter her belongings in the lobby. Security staff then called local law enforcement. Continued review of nursing notes dated 5/21/25 at 3:24 a.m. revealed that P#1 was escorted to the Emergency Department (ED) exit by law enforcement. Continued review of nursing note dated 5/21/25 at 3:27 a.m. revealed that P#1 was discharged.

A review of the "Emergency Medical Treatment and Labor Act - EMTALA" policy, #LD-108, last revised 5/6/22 revealed that it was the policy of the facility to comply with the Emergency Medical Treatment & Active Labor Act (EMTALA) 42 CFR § 489.24, 42 CFR § 489.20 and subsequent federal interpretive guidelines and state regulations. Step Five. Refusal of Treatment. 5.1 Refusal of Treatment. If the Hospital offered the MSE, further examination and treatment and informed the individual or the person acting on the individual's behalf of the risks and benefits of not receiving the examination and treatment, but the individual or person acting on the individual's behalf refuses the examination and treatment, the hospital shall take all reasonable steps to have the individual or the person acting on the individual's behalf acknowledge their refusal of further examination and treatment in writing (against medical advice form). Documentation in the medical record should include information provided to the individual or to the person acting on the individual's behalf. Documentation in the medical record should include information related to the MSE, further examination, and treatment that is being offered to the individual including the risk and benefits of not continuing the examination and treatment. Step Twelve. 12.1 Enforcement. All staff include the procedures described above are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate disciplinary action pursuant to all applicable policies and procedures, up to and including termination. Such disciplinary action may also include modification of compensation, including any merit or discretionary compensation awards.

A review of the "Leaving Against Medical Advice (AMA)" policy, number #PE-14-01, last revised 9/20/22 revealed the purpose was to define a process for working with adult patients with decision making capacity who wish to leave against the medical advice of a provider while respecting the patient's right to reuse any medical treatment. Step One. Patient Refusal of Treatment. An adult patient with decision-making capacity had the right to refuse any medical treatment. 1.1 Advise patient of risks involved in discontinuing treatment or leaving before being discharged. Treating or attending provider, Registered Nurse (RN) or Paramedic: Encourage patient to continue in his/her prescribed course of medical treatment. 1.2 Document in the medical record the patient who insists on leaving against medical advice. Documentation occurs within 24 hours. Patient-provider consultation where patient was advised against leaving and discontinuing treatment. 1.3 Attempt to obtain patient signature on AMA acknowledgement form. Signature acts as patient's acknowledgement of patient's awareness of risks for leaving AMA. Patient refusal to sign AMA acknowledgement form does not relieve the provider of the responsibility for explanation of documentation of risks.

A review of the security incident report #COBB IR-2025-0350 revealed a report by security officer (SO) LL. revealed an incident occurred 5/21/25 at 3:11 a.m. in the ED lobby. Continued review revealed that charge nurse (CN) FF refused to see a patient (P#1) and requested that the patient be removed. CN FF approached me as well as officers SO GG and SO HH and stated that she needed SO GG to come to the ED lobby to remove P#1, whom she stated was being belligerent, laying on other patients, and cursing at staff. When security staff arrived at the ED lobby, P#1 was asleep. Local law enforcement had been notified while security was enroute to the lobby. Law enforcement officers arrived at 3:12 a.m. and was directed to speak with CN FF. Law enforcement escorted P#1 off the property after speaking with CN FF.

A review of the video surveillance of the ED lobby dated 5/20/25 beginning at 10:55 p.m. ending 5/21/25 at 3:23 a.m. revealed the following:
Video dated 5/20/25 beginning at 10:55 p.m. of the ED ambulance bay.
At 10:55:28 p.m. P#1 arrived on EMS stretcher
At 10:57:14 p.m. EMS Paramedic placed P#1's personal belongs next to the stretcher
At 11:01:44 p.m. P#1 transferred from the stretcher to a wheelchair
At 11:03:05 p.m. P#1 was escorted from the ambulance bay to the lobby

Video dated 5/20/25 beginning at 11:03 p.m. of the ED lobby.
At 11:03:06 p.m. P#1 was observed being transported into the lobby via wheelchair.
At 11:04:30 p.m. P#1 was placed in right side corner of the lobby

Video dated 5/20/25 beginning at 11:40 p.m. of the ED Triage Area
At 11:40:06 p.m. CN FF was observed standing next to P#1 who was sitting in wheelchair
At 11:40:11 p.m. SO GG walked over to CN FF and P#1
At 11:42:07 p.m. CN FF escorted P#1 to the triage area

Video dated 5/21/25 beginning at 12:55 a.m. of the ED Hallway
At 12:55:19 a.m. P#1 observed sitting in a wheelchair
At 12:55:23 a.m. RN MM escorted P#1 down the hall

Video dated 5/21/25 beginning at 12:55 a.m. of the ED Lab Area
At 12:55:31 a.m. RN MM escorted P#1 to lab room T#3

Video dated 5/21/25 beginning at 2:22 a.m. of the ED Triage Desk
At 2:22:12 a.m. P#1 observed walking to the triage desk and appeared to be talking to staff.
At 2:22:16 a.m. CN FF walked past P#1
At 2:22:25 a.m. P#1 was observed standing at the triage desk and CN FF sat at the triage desk
At 2:22:39 a.m. P#1 turned to SO JJ and appeared to have a conversation

Video dated 5/21/25 beginning at 2:28 a.m. of the ED Triage Area
At 2:28:08 a.m. P#1 observed sitting in the triage waiting area
At 2:28:18 a.m. P#1 appeared to speak with CN FF and SO JJ
At 2:28:22 a.m. P#1 stood up from her chair and spoke with SO JJ
At 2:28:35 a.m. SO JJ appeared to speak with CN FF
At 2:28:42 a.m. P#1 and SO JJ appeared to have a conversation
At 2:29:59 a.m. P#1 returned to her seat in the lobby and SO JJ returned to the weapons detection area at the front door of the ED

Video dated 5/21/25 beginning at 3:13 a.m.
At 3:13:06 a.m. P#1 was observed sitting in far-right hand corner alone with her personal items
At 3:13:10 a.m. A law enforcement officer was observed entering the ED Lobby
At 3:13:13 a.m. SO LL escorted law enforcement officer to CN FF who sat at the triage desk
At 3:14:47 a.m. Law enforcement officer walked over to P#1
At 3:15:02 a.m. A 2nd law enforcement officer walked over to P#1
At 3:15:14 a.m. SO LL walked over to the two officers and P#1
At 3:18:04 a.m. P#1 stood up from her chair and gathered her personal belongings
At 3:20:31 a.m. Law enforcement officers escorted P#1 out of the ED lobby

Video dated 5/21/25 beginning at 3:21 a.m. of the outside of the ED entrance
At 3:21:05 a.m. P#1 observed walking out of the ED doors
At 3:21:07 a.m. Law enforcement officer observed carrying P#1's personal belonging in a plastic bag
At 3:23:46 a.m. P#1 observed getting in the backseat of the police vehicle.


An interview was conducted with Charge Nurse (CN) FF on 6/4/25 at 8:30 a.m. in the administration conference room. After CN FF reviewed her notes in P#1's medical record she stated that she did recall P#1. She stated that she was familiar with P#1 because she (P#1) came to this facility often. She continued to explain that on the day of this incident, P#1 was constantly being loud and disruptive in the Emergency Department (ED) lobby. She continued to explain that P#1 was yelling at the staff in the back that her testing could not be completed. CN FF stated that if a patient is yelling and being disruptive that the staff does not have to deal with that. She continued to explain that she recalled P#1 laying all her personal belongs all over the floor in the ED lobby, spilling her popcorn on the floor and laying on other patients in the lobby. CN FF stated that staff made numerous attempts to continue with P#1's treatment per the provider's order but P#1 continuously told staff to leave her alone because she was sleeping. CN FF continued to explain that P#1 would not cooperate with anyone and continued to be loud and disruptive. She continued to explain that when there are disruptive patients in the ED sometimes, she would ask the provider to come lay eyes on the patient. She continued to explain that because P#1 continued to refuse treatment she asked hospital security to call local law enforcement to have P#1 removed from the facility. CN FF stated that she advised the provider of P#1's refusal to continue with treatment and the provider agreed to discharge P#1 against medical advice (AMA).CN FF stated that she did not review the AMA form or discuss the risks of discontinuing care with P#1. She continued to explain that the facility security officers tried to de-escalate P#1 several times prior to the police being called. CN FF did not recall speaking with law enforcement when they arrived at escort P#1 from the ED. CN FF stated that she was familiar with EMTALA and received EMTALA training annually.

A telephone interview was conducted with Security Officer (SO) GG on 6/4/25 at 12:00 p.m. SO GG recalled P#1, and the night law enforcement arrived at the facility Emergency Department (ED) to escort P#1 off the property. SO GG recalled that CN FF notified him that P#1 was being disruptive in the ED lobby. SO GG continued to explain that when he, SO HH, and SO LL arrived at the ED, he witnessed P#1 sitting quietly in the ED lobby and was not displaying any disruptive behaviors. He continued to explain that CN FF stated that P#1 had to go because she was laying on other patients, was being combative, and cursing at the staff. SO GG stated that he did not witness any of this behavior. He continued to explain that he went with SO LL to review the camera footage to determine if P#1 was being disruptive in the ED lobby. SO GG stated that after reviewing the camera footage, they determined that P#1 was not disrupting the waiting room in the manner that CN FF stated. He continued to explain that they could see P#1 sleeping at times, getting up to speak with SO JJ, and trying to maintain her personal belongings. SO GG stated that he did not feel law enforcement should have been called for P#1. He continued to say that he did not have to de-escalate P#1 at any time. He continued to explain that once the police arrived, they asked security what was going and was referred to CN FF because she had them dispatched to the facility for P#1. He continued to explain that after the police officers spoke to CN FF, they escorted P#1 from the ED.

A telephone interview was conducted with Security Officer (SO) HH on 6/4/25 at 12:30 p.m. SO HH stated that he did recall the incident concerning P#1 however, he was not involved in having P#1 removed from the Emergency Department (ED). He continued to explain that he was present when CN FF requested SO GG to come to the ED to remove a patient from the ED and when he arrived at the ED several minutes later, police officers were already on the scene. SO HH stated that during the few minutes he was present in the ED, P#1 did not display any behaviors and was not disruptive at the time.

An interview was conducted with Emergency Department Executive Director (ED) II on 6/4/25 at 2:15 p.m. in the administration conference room. ED II confirmed that after review of the video surveillance that there were no visual attempts from RN FF to explain to P#1 the risks of discontinuing her medical treatment and leaving the hospital. ED II confirmed there is no record or visual attempt from the provider to explain the risks of discontinuing medical treatment. ED II stated that P#1 had been seen several times in the ED for various reasons. He continued to explain that she had been seen in the past by Care Coordinators to assist with resources and in getting help for her circumstances. He confirmed that Care Coordination (CC) did not see her in person during this visit to the Emergency Department (ED); however, there was a note from her previous visit that CC did reach out to her by telephone with no luck in reaching her. ED II stated that all ED staff were required to complete EMTALA training annually as well as attend staff meetings where EMTALA was reviewed periodically.


A telephone interview was conducted with Security Officer (SO) JJ on 6/4/25 at 3:00 p.m. SO JJ stated that she did recall P#1, and she is familiar with her from this incident and past visits to the Emergency Department (ED). SO JJ stated that on the evening of 5/20/25 into the morning of 5/21/25 she worked in the ED at the weapons detection area at the front door. She continued to explain that she recalled P#1 in the ED lobby and sleeping most of the time. She continued to explain that at one point during the evening a tech came to the waiting room to get P#1 for a test, and she had to wake up P#1 and as a result P#1 refused to have the test saying that she (P#1) was sleeping. SO JJ continued to explain that after P#1 refused to wake up to get a test done, CN FF said that P#1 had to go. SO JJ stated that CN FF continued to say that P#1 was combative in the back and disruptive in the lobby and there was no evidence of P#1 doing any of those things. She continued to explain that CN FF said that P#1 refused to get her test, and SO JJ only observed P#1 refusing once. SO JJ stated that CN FF continued to complain that P#1 was laying on other patients in the waiting room and spilling her popcorn. She continued to explain that during the time P#1 was in the waiting she did not witness her laying on other patients, and she did not spill any food while in the waiting room. SO JJ stated that she had to speak to P#1 once when she came to the triage desk where CN FF was sitting because she (P#1) was talking loudly. SO JJ recalled telling P#1 that if she refused treatment then she will have to leave the ED and that is when P#1 sat in the chair closest to CN FF and said okay, I'm ready for the test now. SO JJ stated that when P#1 agreed to have the testing done, CN FF said no she had to leave because she (P#1) had been disruptive. SO JJ stated that CN FF was wrong, and that P#1 may have raised her voice, but she was not disruptive and should not have been made to leave the ED by the police when she came to the hospital seeking treatment.

A telephone interview was conducted with Security Officer (SO) KK on 6/4/25 at 3:30 p.m. SO KK recalled the incident involving P#1's most recent visit to the Emergency Department (ED) when she was escorted out by law enforcement He continued to say that he was in the waiting room when P#1 arrived and that she (P#1) was little loud at first but not disruptive in anyway. He continued to explain that CN FF called security to have P#1 removed from the ED for no reason, P#1 was not doing anything. He continued to explain that CN FF went to speak with SO LL again to have P#1 removed and at the time P#1 was sitting in a corner with the blanket over her head not bothering anyone waiting her turn to be called to the back. SO KK stated that at some point, CN FF requested law enforcement be called to come to the ED, wake up P#1, and have her removed. SO KK stated during his shift in the ED he did not witness P#1 being disruptive, spilling food, or bothering other patients in the waiting area.

A telephone interview was conducted with Security Officer (SO) LL on 6/4/25 at 6:00 p.m. SO LL stated that she did recall P#1 and the incident where the police escorted her from the Emergency Department (ED). SO LL went to the ED with SO GG and SO HH to see what they could do to help with P#1 at CN FF's request. SO LL stated that when they arrived at the ED, P#1 was sitting in the corner and appeared to be asleep. She continued to explain that CN FF stated that P#1 was being disruptive, loud, cursing at staff, spilling popcorn on the floor, and bothering other patients in the ED. She continued to say that when they arrived at the ED, P#1 was not displaying any of these behaviors. SO LL stated that when law enforcement she directed them to CN FF since she was complaining about P#1. SO LL stated that she remained on the scene while the police officers were in the ED. She continued to explain that after the police officers spoke with CN FF, they approached P#1 and informed her (P#1) that she was being requested to leave the facility.

In summary, the hospital failed to complete an appropriate medical screening examination for P#1. There was no documentation in the medical record of a psychiatric evaluation, neurological exam, testing to rule out a myocardial infarction, evidence a qualified medical person determined P#1 to be competent to refuse care and no documentation of an informed refusal.