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Based on observation, interview and record/video review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to provide an appropriate medical screen exam for Patient ID #1.

Refer to tag A2406 for additional information.

Based on record review, and interview, the facility failed to conduct a complete medical screen examination, to determine whether an emergency medical condition exited, for (1) one (Patient #1) out of (21) twenty-one medical records reviewed of patients having arrived at the facility's emergency department seeking treatment. The facility failed to complete the medical screen evaluation (MSE) for patient #1's leg and back pain. The patient was escorted out of the facility by hospital security staff and then was brought back into the facility after a 911 call with Houston Fire Department (HFD) seeking treatment again shortly later. Patient ID #1 then left Against Medical Advice (AMA). Patient ID #1 returned a third time with Police Department Crisis Team with a new behavioral health complaint of suicidal ideation. She was taken by facility A staff to Facility B Emergency Department via wheelchair without a medical screen examination being performed.

Findings included:

Record review of facility policy titled "Emergency Department Medical Screening Procedure," dated 11/9/2021 showed the following information:

"III. PROCEDURE
3.1 General Procedure: Pursuant to HM Official Procedure PCPS002, when an individual Comes to the Emergency Department, the ED must provide an appropriate Medical Screening Examination within the capability and capacity of the ED, including ancillary services routinely available to the ED, to determine whether or not an Emergency Medical Condition exists. The Medical Screening Examination must be conducted by a Qualified Medical Personnel, as permitted in the applicable hospital's rules, bylaws or regulations.

No Houston Methodist Entity may delay providing an appropriate Medical Screening Examination or any necessary stabilizing treatment in order to inquire about the individual's method of payment or insurance status, to collect payment, or to seek authorization from a third-party payor. HM hospitals may follow reasonable registration processes as long as the registration process does not delay any Medical Screening Examination or treatment, nor discourage individuals from remaining in the ED for evaluation or treatment. An emergency physician or nonphysician practitioner is not precluded from contacting the individual's physician at any time to seek advice regarding the individual's medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services as described in this Section 3.1.
3.2 ESI AND MSE: All individuals who come to the Emergency Department will be triaged utilizing the Emergency Severity Index ("ESI") five level triage tool and will receive an MSE by a QMP to screen for an Emergency Medical Condition. An individual who Comes to the
Emergency Department and who, after undergoing an MSE by a QMP, is deemed to have an Emergency Medical Condition will be provided with any necessary stabilizing treatment, or transferred to another facility in accordance with PCPS002

I. Determination of Non-Emergency Medical Condition
4.1 Except for the population described in Section 4.2, an individual who comes to the Emergency Department who, after undergoing an MSE, is assessed as not having an Emergency Medical Condition, will continue through the ED care process as described below. If at any time it is determined that an individual who previously was assessed not to have an Emergency Medical Condition is reclassified as having an Emergency Medical Condition, then the individual will receive all necessary stabilizing treatment or be transferred to an appropriate medical facility, in accordance with PC/PS02, regardless of that individual's ability to pay for such treatment. All individuals, regardless of the ESI level at which they are triaged, will receive an MSE by a Qualified Medical Personnel prior to any inquiry about the individual's ability to pay, and any individual determined to have an Emergency Medical Condition will receive all necessary stabilizing treatment or be transferred to an appropriate facility, in accordance with PCPS002, regardless of that individual's ability to pay for such treatment."

Medical record review at Facility A failed to locate a central log entry or medical record encounter for Patient ID #1 who presented with law enforcement to Facility A for evaluation on 6/26/2024 in the early morning hours.

Review of the Houston Methodist Hospital Medical record for patient #1 dated 06/25/24 reflected:

History of Present Illness
Patient #1 is a 39 y.o. female with a PMHx of sickle cell disease, bipolar disorder, diabetes, DVT on Eliquis, HIV presenting to the ED due to back pain and leg pain that started recently. Pt reports that she fell while on the bus and also reports that she was beat by her boyfriend. Pt c/o of diffuse back pain as well as leg pain. Pt is very sedate and has slurred speech, needing to be aroused at the beginning of her evaluation. Pt is also demanding IV narcotics. Pt also interrupted meeting with another pt with yelling. Pt was seen at this facility earlier today for syncopal episode.

Medical Decision Making
Patient with back pain and leg pain. Labs were considered to rule out strain, sprain, fracture, dislocation, radiculopathy. I reviewed previous ER notes, Discharge summary, Clinic note, Labs, CT, XR, US, and EKG.

Orders Placed This Encounter
naloxone (NARCAN) 0.4 mg/mL injection 0.4 mg
acetaminophen (TYLENOL) tablet 1,000 mg

Details: "Patient demanding IV Dilaudid for her chronic pain. Patient states that she has since been out of her medications. Review of the patient is a she is recently filled multiple patient medications. Patient also stated that she has a history of sickle cell SS however review of her lab work shows she does not have any sickle cell disease. Hemoglobin have always been mildly anemic but nowhere near level for patient for sickle cell SS. Patient became increasingly aggressive. At one point patient barged into another patient's room I was interviewing another patient and was incredibly disruptive and yelling at me plan for IV narcotics. Security was called and patient was escorted off the premises. (Encounter 2 begins here). Patient then rechecked. VSS. Patient refusing attempts of lab draws or line placement. Lab work was ordered for further evaluation patient became frustrated with complaints patient has not received IV narcotics patient eventually left AGAINST MEDICAL ADVICE threatened to report everyone to the board."

ED Timeline (Included):

23:10 ED Notes Pt was agitated, aggressive, and yelling while in intake, as she was being taken to CT via wheelchair. Pt started to yell at ED
attending as he was in another room with another patient.
Security called as per request by Dr. Pt escorted out.

00:15 ED Quick Updates - Free Text: Contacted CT, CT does not have patient at this time

00:27 ED Quick Updates Free Text: brought in again by HFD. was told that pt called 911 from the outside

01:46:24 ED AMA Disposition

Patient #1 was seeking treatment for leg and back pain, patient was escorted out of the facility prior to MSE completion. Patient returned to the facility after calling 911 and was not reassessed for change in condition and previous course of treatment. No labs or imaging was completed prior to the patient being escorted out or prior to leaving against medical advice (AMA). There was no evidence of Patient ID #1's third encounter located in Facility A electronic medical record or central log. Per interviews and record/video footage review, she presented a third time with Texas Medical Center Crisis Team Police force with new complaint of suicidal ideation.

Medical record review of Facility B's records for Patient ID #1 shows that Patient #1: Arrival 6/26/24 at 03:14 am, "Acuity-Emergent" Means of Arrival - Other", Method of Arrival "Other"; "Arrival Complaint - Patient brought in from a (Facility A) employee"; ED Encounter created 03:14 am; Chief Complaint "Altered Mental Status."

Review of Facility B Video Footage labeled "Camera 12" and identified by Facility B Security Staff ID #97 as Facility B Emergency Department Ambulatory Entrance dated 6/26/2024 at 03:08:25 am. The clip shows an African American female patient, identified by Facility B Director Of Quality Staff ID #96, as Patient ID #1. The patient is seated in a wheelchair and bent over at the waist, wearing a gold top and pants. The wheelchair is being pushed by a uniformed male with a dark jacket and pants on. The male staff member who is pushing the wheelchair speaks to Facility B female employee seated behind the desk. She comes from behind the desk at 03:09:17 am and appears to stoop down to patient level. At 03:09:26 am she is speaking to the patient and the patient is noted to slowly sit up in the chair. 03:10 am she hands patient her purse which is draped over back handle to wheelchair. 03:10:48, the male employee walks to adjacent hallway and retrieves a wheelchair. He transfers patient's personal purse/bag and another clear belonging bag to back of Facility B's wheelchair. He stimulates the patient and points for her to move to other wheelchair. The patient is noted to stumble and walk toward wheelchair and has white sheet (which she arrived with), draped around her shoulders. He pushes the original wheelchair out the door and leaves patient unattended, slumped over in wheelchair, in the hallway at 03:12 am.

Interview with ED Nursing Director #52 on 8/5/24 at 11:04 she stated that if a patient leaves the ED, has a change in condition, and/or shift change occurs, the patient should be reassessed. When reviewing medical record for patient #1, she stated that the patient technically should have been reassess after she was escorted out of the facility and returned via 911. It looks as if the staff saw that the patient was still in the system and continued down the path from her earlier encounter. She stated that she would have expected that the staff would have at least asked if anything had changed.

Video interview with Facility A Security Officer Staff ID #69 on 8/6/24 at 06:15 am. He recalled the events of June 25 night shift. He stated Patient ID #1, (he did not recall her name), "was 'discharged' and it was our job to ensure she was safely escorted off the premises." Once she was "discharged, she was on the front sidewalk on Fannin Street" adjacent to Facility A and she called fire department and they brought her back in a wheelchair to the ED. He stated "medical staff tried to engage in appropriate medical care and she was not able to be treated." He stated "she was escorted off the premises by Facility A security staff. While being escorted off the premises, she made the statement she was going to lie on Fannin street and kill herself." He stated "a big discussion" ensued between Facility A team (he did not identify who was involved in this discussion). He stated that she had been returned the facility for a third time that night by Texas Medical Center (TMC) police officer with their "crisis team" who stated "he couldn't' leave her out there. She was not in the condition to be left out." Security staff ID #69 stated "medical staff had exhausted all opportunities and she had to be escorted off." He stated that Facility B hospital was the next available facility. Staff ID #69 stated he needed to "get her out of the building, we can't keep taking her back to the same place. They didn't want her back in the ER." He said "I was trying to avoid her laying in the street and getting killed." He stated "she wasn't alert and she wasn't moving and I don't know if she was dead or alive." He confirmed that he rolled patient, in the wheelchair to Facility B and dropped her off in their ED. He confirmed he had not completed any security or facility incident reports. He stated that Facility A dispatch and night shift security manager were aware of the encounters with Patient ID #1.

In summation, Patient ID #1 was a 39-year-old female who presented to Facility A initially for the evaluation of back and leg pain in the setting of reported traumatic injuries which included a fall and physical assault. The medical screening examination was inappropriate as it lacked thorough history, physical examination, imaging, and laboratory components, that would be needed to evaluate for emergency medical conditions. No emergency medical condition was identified. Citing aggressive, disruptive behavior, Patient ID #1 was escorted from the emergency department by security staff at the direction of the medical team. Patient ID #1 represented a short while later to Facility A for a second encounter and refused treatment and subsequently left against medical advice. Patient ID #1 presented for a third encounter that shift, accompanied by Texas Medical Center police crisis team, after making a statement that she was suicidal with a verbalized plan. Facility A security staff transported Patient ID #1 via wheelchair to Facility B emergency department without Facility A performing a medical screen examination for her new mental health complaints and without coordinated transfer.