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Based on observation, review of recorded video footage, interviews, review of medical records and other documentation of 1 of 20 patients who presented to the hospital's ED (Patient 8), and review of policies, procedures, and other documents, it was determined the hospital failed to enforce its EMTALA policies and procedures to ensure that Patient 8, who presented to the hospital's ED, was provided a MSE. However, the hospital had identified that failure and taken corrective action prior to the onsite EMTALA investigation.

Findings include:

1. Refer to the findings identified under Tag A2406, CFR 489.24(a) and (c) which reflects the hospital's failure to enforce its EMTALA policies and procedures related to the provision of an MSE for Patient 8.

Based on observation, review of recorded video footage, interviews, review of medical records and other documentation of 1 of 20 patients who presented to the hospital's ED (Patient 8), and review of policies, procedures, and other documents, it was determined the hospital failed to enforce its EMTALA policies and procedures to ensure that Patient 8, who presented to the hospital's ED, was provided a MSE. However, the hospital had identified that failure and taken corrective action prior to the onsite EMTALA investigation.

Findings include:

1. The hospital's policy and procedure titled "EMTALA (Emergency Medical Treatment and Active Labor Act)", dated as revised "11/15" was reviewed. It stipulated the following: "It is the policy of the hospital to comply with the EMTALA obligations...The hospital will provide a [MSE] by a qualified medical provider to any individual who comes to the hospital seeking emergency medical treatment (or requested on their behalf); determine if the individual seeking care has an [EMC]; and, if an EMC exists, provide the individual with further medical examination and treatment as required to stabilized the [EMC] or arrange for transfer..."

The hospital's "Bylaws and Rules and Regulations of the Professional Staff", dated "September 2015" were reviewed. The section titled "Attendance of Patients in Emergency Situations" required that "An appropriate [MSE] within the capability of the hospital...shall be provided to all individuals who come to the [ED] and request (or on whose behalf a request is made) examination or treatment. Such medical screening shall be provided by qualified medical personnel."

2. The ED central log was reviewed and reflected that Patient 8 arrived to the ED on 12/01/2015 at 0723. The "Reason for visit" was recorded as "Other", the "Disposition" was recorded as "[LWBS]", and the departure time was recorded as 12/01/2015 at 0753.

3. The ED medical record for Patient 8 reflected that the patient arrived by ambulance in the ED on 12/01/2015 at 0723. The "Arrival Complaint" was recorded as "exposure." The "Acuity" level was blank. At 0728 the RN recorded "Presenting History...pt was found by police, complains of being 'cold and wet, and I need my thyroid medications'...pt has flight of thought and slurred speech, randomly yelling, and denies any ETOH or drug use." At 0731 the RN recorded triage data on the Stroke Scale, Sepsis Screening Tool, C-Diff Screening, Schmid Fall Risk Assessment, and Psychosocial sections of the record. There was no evidence that vital signs were obtained or other examination or care provided.

At 0744 The ED RN Manager recorded "Pt verbally abusive to staff, does not want to be assessed, verbalized that wants to sleep and be left alone because it is cold outside; refusing to participate in care; requested security to escort off campus." At 0753 the RN recorded "Ed Disposition set to [LWBS]." The entry under the "ED Disposition" section of the record reflected "[LWBS] Pt screaming to staff, threatening in nature. Verbal obscenities to this RN...Charge RN aware...ED Manager in the room with patient at the same time. Continued to ask patient to calm down and keep self and staff safe. Pt continues behavior and will not stop. Pt putting fists up to [ED Manager] and this RN however no physical contact was made. Pt continues to scream at security that has come to assist with safety. Pt then escorted out of the ER by security and off Kaiser property."

The 12/01/2015 ED medical record additionally contained the pre-hospital ambulance report that reflected the ambulance was dispatched to the patient on 12/01/2015 at 0653. The report reflected the ambulance crew found the patient "...complaining of being cold. Arrived on scene to find the pt sitting on the ground in the care of police and fire. Pt states...just got out of Kaiser Sunnyside. Pt was very active and appeared to be having trouble sitting still. Pt states that...got the black eye...from [his/her] fiance a couple days ago...Pt states that [he/she] knocked on the door of the house here and asked them to call 911. Pt was able to stand and walk over to the gurney with EMS assistance. Pt states...has had some alcohol...en route to the hospital the pt remained stable. Pt denies any other complaints..."

The 12/01/2015 ED medical record additionally contained laboratory test results for blood work done during the patient's prior ED visit on 11/30/2015, the previous evening.

There was no evidence in the 12/01/2015 ED medical record that the patient was examined or treated by a physician.

4. During interview with the Associate Medical Director on 12/15/2015 at 1230 he/she confirmed that MDs, DOs, CNMs, PAs, and NPs were authorized to perform MSE's in the ED. He/she stated that RNs were not authorized to perform MSEs in the KSMC ED.

5. During interview with the ED Nurse Manager on 12/15/2015 at 1300 he/she stated that Patient 8 had presented and been examined in the ED on 11/30/2015, the evening prior to the 12/01/2015 visit. He/she confirmed the information documented in the 12/01/2015 ED record and stated that on 12/01/2015 Patient 8 didn't present with a medical complaint and wanted food, a place to stay, and a shower. He/she stated that on 12/01/2015 the patient refused vital signs, put his/her head under the blanket, and told staff to get out of the room. The ED Manager stated that eventually the patient was escorted out of the ED by the security officers and carried the hospital blankets with him/her.

6. A Safety/Security Event report was completed by a hospital security officer and dated 12/01/2015. The report reflected that on 12/01/2015 the officer "Responded to [ED triage room] for a disorderly...patient...was yelling, screaming and being vulgar towards staff. Myself [and two other security officers] escorted [patient] off property. Cleared at 0744."

7. During interview on 12/15/2015 at 1345 a security officer who responded to the ED on 12/01/2015 stated that upon arrival to the ED triage room, he/she observed Patient 8 to be standing up and verbally aggressive towards staff. The officer stated that the patient eventually deescalated and walked out of the ED through the main entrance and no hands were placed on the patient during the encounter. The officer stated that he/she and other officers accompanied the patient across the hospital property to the main road. He/she stated that only officers who have received special training may carry pepper foam and that he/she had not received that training and did not carry pepper foam. The officer stated that no force, including pepper foam, was used on Patient 8. A second security officer was interviewed on 12/15/2015 at 1545 and described the encounter with Patient 8 similarly.

8. Interior video-footage of the main ED lobby area was reviewed on 12/16/2015 at 1130. The recording reflected that on 12/01/2015 at 0745 the patient and three hospital security officers exited an ED triage room and walked through the waiting room, past the registration desk, and out of the main entrance doors. Video footage of the hospital exterior reflected that the patient and the officers walked through the parking lot and towards nearby Sunnyside Road. The patient was observed to be walking independently and calmly, without distress. There was no observation that the officers laid hands on or used other measures on the patient.

9. During interview with the Director of Quality and Patient Safety on 12/15/2015 at 1415 he/she stated that a team had reviewed the case of Patient 8 to evaluate how the patient left the hospital without an MSE.

10. A document titled "ED Event Summary" was reviewed. It reflected that Patient 8's 12/01/2015 ED visit had been reviewed and a meeting conducted by a group of 13 hospital medical, nursing and quality leadership staff on 12/02/2015. The report reflected the "staff account" of the event and included "patient arrived via ambulance, with request to sleep and eat. Refused to allow nurse to assess [him/her] and was potentially physically violent (spitting and swinging [his/her] arms about and verbally abusive). Other staff came to support triage nurse, attempting to establish rapport and deescalate. Patient clearly articulating that [he/she] was in 'here for a meal and a shower' and told staff [he/she] did not have any medical needs. Continued very demanding for non-medical needs...continued to belligerently demand a meal and a shower. Security was summoned because of the verbally abusive behavior and threat of harm to staff. Security escorted patient off of the property."

The summary reflected the team had identified "Breakdown in Safe Behaviors." It reflected that "RN staff did not consult with physician prior to the patient being escorted out of the ED. This prevented the physician from performing (or at least offering) the MSE...With the exception of failing to notify the physician the staff worked well as a team. Other nurses tried to assist with establishing rapport, and de-escalation. The manager was quickly notified of the situation and attempted to work with the patient to identify [his/her] medical need, and complete the triage. Upon learning of the event through our audit process, hospital leadership was notified of the breakdown."

The summary reflected the team had identified "Breakdown in Process or Procedure." It reflected that "The review revealed that our staff have developed a very good understanding of the rules associated with EMTALA compliance, for any patient who presents with a stated (or obvious) medical need. This case presented a very unusual circumstance for our staff to apply the rule for a MSE because of the patient's clear articulation for the purpose of [his/her] visit being a meal and shower...We reviewed the language in the EMTALA requirements and were able to see how the staff may have unknowingly violated a standard because of the patients stated reason for visit, appearance and articulation that [he/she] was not in the ED for a medical need...We determined in our review that the appropriate MSE, which is up to the physician to perform was not completed, and that our breakdown in communication prevented the physician from providing (or at least offer) this to the patient. We speculate that the patient would likely have refused the exam, however, the patient had the right to be offered the exam (and then to refuse it) if [he/she] was not seeking medical care."

The summary reflected the team had identified "Breakdown of Competency or Training." It reflected that "Explicit instruction on this specific type of circumstance was not included in recent EMTALA education. Education consistent with the requirement to 'Provide an appropriate MSE to any individual who comes to the [ED]' was abundantly reinforced, however we did not call out what to do if there is an apparent social need prompting the visit in the absence of a medical need or complaint."

The summary reflected the team had identified "Immediate & Remedial Actions Taken." It reflected that "12/1/15: The physician and nurses working on this day were provided immediate verbal face to face clarification that even if a patent explicitly states that they have no medical needs associated with their visit that the following must occur: Always follow the usual process for triage, establishing acuity and providing a [MSE]. In the event the patient refuses the triage process, notify the ED physician to examine the patient, attempt to provide the MSE and/or determine next steps."

The "Actions Taken" continued "12/2/15: Education and Training at the ED physician's monthly meeting about this event, the associated EMTALA requirements, and that nurses will notify the ED physician whenever a patient comes to the ED, yet is denying the need for treatment and/or refusing treatment. Completed by [Associate Medical Director and other MD]. Email notification of nursing staff about the EMTALA requirements was started to always notify the ED physician of a patient who denying the need for treatment upon presentation to the ED. Training will be completed at huddles throughout the week. Completed by [ED Nurse Manager and ED Associate Nurse Manager]."

The "Huddle Message" attached to the summary contained the following direction: "...If a patient refuses to wait to see the Doctor, we need to immediately notify the Doctor so that THE DOCTOR can go see the patient before the patient departs. If a patient is offered an MSE but refuses - this is important to document in the chart. This is necessary for all patients - AMA, Left without being seen, eloped, etc..." The document reflected that the "message was given by ED Leadership...at the staff huddles before every shift 0600 & 1800 from 12/02/2015 to 0600 12/14/2015...The message was also communicated via email and a brief synopsis of the email has been placed on the departments huddle board...posted in the staff break room, locker room, and bathrooms..." A copy of the email reflected the distribution to all ED staff on 12/02/2015 at 2144.