HospitalInspections.org

Based on staff interviews, review of medical records, review of facility policies and procedures, and review of facility documents, it was determined that the facility failed to perform a medical screening exam (MSE) for one patient with an emergency medical condition (EMC) (A2406).

Cross reference with:

489.24(a) and 489.24(c) - Medical Screening Exam: A2406

Based on review of Medical Record #1 (MR1), staff interviews, and review of facility documents, it was determined the facility failed to ensure that all patients presenting to the Emergency Department (ED) receive a medical screening exam.

Findings include:

On 7/26/23 at 10:42 AM a tour of the ED was conducted in the presence of S6 (ED Medical Director), S7 (ED nurse manager(NM)), and S8 (EDNM). EMTALA signage was observed in all patient care areas. At 10:46 AM during tour of the ED, 4 of 4 staff members interviewed (S17 (ED Tech), S18 (Registered Nurse(RN)), S19 (RN), and S20 (ED Unit Clerk) stated that staff had reviewed EMTALA training and that it is conducted annually. 4 of the 4 were able articulate EMTALA: S17 stated that no patient can be turned away; S18 and S19 both stated that all patients have a right to a medical screening exam and cannot be denied care; and S20 stated that patients cannot be turned away if they do not have medical insurance.

Upon review of medical records (MR) with dates from February 2023 thru July 2023, 1 of 24 medical records selected (MR1) revealed evidence that a medical screening exam was not provided.

Review of MR1 on 7/27/23 at 10:02 AM revealed the following:

Patient #1 (P1) presented to the ED on 5/23/23 at 6:11 PM. Upon arrival, P1's chief complaint was documented as, "Was supposed to be here yesterday to receive IV (intravenous) antibiotics. Admits to ETOH (alcohol) and drug use." P1 was triaged and assigned an acuity level of 2. Vital signs were completed.

Nurse's notes dated 5/23/23 at 7:30 PM state, "... Pt (patient) arrived, registered and was instructed to wait in the lobby for a room. Pt became agitated and threatened triage RN, stating, 'I'm going to shoot you in your face.' " Security and PD (police department) involved, pt escorted by the PD off site."

ED provider notes dated 5/24/23 at 9:29 AM state, "Pt [sic] threatened to shoot RN (registered nurse) in the face. pd called and removed pt from the premises."

Further review revealed no evidence in the medical record that P1 received a medical screening exam during the ED visit of 5/23/23.

Facility policy titled, "Medical Screen Exam" (last reviewed 11/7/22) states, " ... Every patient presenting to triage is considered an Emergency Department/S.E.D. (satellite emergency department) patient by virtue of their request for medical treatment and will receive a medical screening exam by the physician/Resident/APC (advanced practice clinician) on duty. ... B. Physician Procedure: 1. The on-duty emergency physician/Resident/APC shall provide a medical screening examination to all patients presenting. Except in the case of a documented refusal, AMA (against medical advice), or instance of a patient leaving without being seen, no patient shall be discharged from the emergency department/S.E.D. without having been seen by a physician/APC. ... ."

Facility document authored by S40 and titled, "Incident 5/23/23" (dated 5/24/23 at 12:12 AM), reviewed in the presence of S3, stated that S42 (ED assistant nurse manager) reported that P1 presented to the ED with a hand injury. When P1 was asked to wait, the patient became irate and began using foul language, screaming at staff, and claimed to have a firearm, threatening to shoot the ED staff and specifically one RN in the face. S42 reported that security and the local PD were called for assistance. S42 reported that the PD was with P1 and asking if the patient could be seen if [he/she] behaved. S42 reported that the staff did not feel safe in the presence of P1. S40 stated that he/she advised S42 to have P1 "trespassed off the property." S42 and S43 (security guard) reported that P1 had been escorted off the property. S40 stated that the ED charge nurse at another facility was notified that if P1 "should present there and make any threats or cause issues to call the [local PD] and trespass [P1] from there as well." S40 continued that during a follow up, S42 reported that the PD had returned to the ED after escorting P1 out, and stated, "if someone would wrap [P1's] hand that [he/she] would promise to leave." S40 continued that the "PD was asked to remove [P1] as per the trespass request..." S40 added that S43 had made their administration aware and that "they also alerted all campuses about [P1] ..."

Facility document titled, "Safety/Security-Management Form" dated 5/23/23 states, "On ... May 23rd 2023 at 18:24 [6:24 PM] officer [S45] (security officer) responded to the nursing triage desk/waiting room area for a male that was waiting to be medically seen... The patient was visibly agitated and proceeded to make a verbal terroristic threat to RN [S46]... The patient was dissatisfied with [his/her] wait time... the male told [S46] around 18:24 [6:24 PM] that [he/she] was 'gonna shoot [S46] and this hospital up with a gun' and if [he/she] wasn't medically seen soon and made sexual assault threats to [S46]...At 18:49 [8:49 PM] [ Police Department] was on site ... and escorted [P1] to the outside front entrance of the emergency department. [P1] was told [he/she] was not allowed on the property because of [his/her] threats to the staff member. 19:30 [7:30PM] [P1] walked away from [police officer] and off hospital premises. Security manager ... and Security Director ... were notified of the incident."

Review of the local police report dated 5/25/23 at 7:52 AM states, "... A highly intoxicated/agitated [P1] got into a verbal dispute with nursing staff and allegedly threatened to shoot them while in the emergency room waiting area. [He/She] was ultimately no longer welcome on the property and subsequently sent on [his/her] way after an extensive effort to assist [him/her] to obtain other medical treatment failed due to [his/her] unwillingness to cooperate... ."

Upon interview on 7/28/23 at 1:11 PM, Staff (S)36 identified him/herself as the administrator on call on 5/23/23. S36 stated that he/she received a call at approximately 7:15 PM from S40 (Nursing Supervisor), who reported the following: A patient who had presented to the ED under the influence of drugs and alcohol, was verbally abusive and threatened to shoot a nurse. The nurse reported that ED security did not attempt to de-escalate the situation. The police were contacted, arrived, and had taken the patient outside, but was not seen searching the patient for a weapon. Police then brought the patient back in the ED and asked, "What do you want us to do?" S40 then reported that the patient was asked to leave. S36 stated after his/her conversation with S40, he/she notified S41 (ED Director).

Upon interview on 7/28/23 at 1:31 PM, S41 stated the following: S36 notified him/her on 5/23/23 of an ED patient threatening to shoot a nurse. S36 reported the police had been notified. S41 stated that he/she was not informed of whether the patient had received a medical screening exam. S41 stated that his/her focus was on the violent behavior of the patient and that a staff member was being threatened. S41 stated that he/she notified S3 (Vice President of Clinical Operations).

Upon interview on 7/28/23 at 1:45 PM, S3 stated that on the evening of 5/23/23, he/she received a call from S41 reporting that a patient in the ED had threatened to shoot a nurse, the police were on site, and that the patient had been transported off the premises. S3 stated that he/she did not notify anyone else at that time. S3 stated that he/she received a full report the morning of 5/24/23 and "recognized there was an issue and a possible EMTALA violation." S3 stated at that point, he/she notified the ED Medical Director. S3 stated, "Once we identified there was an issue, we reported the incident to DOH (Department of Health) and came up with an action plan."

Education documement titled "EMTALA Education, Security Staff Meeting " dated June 29 and document titled "EMTALA" along with staff sign in sheets were reviewed and revealed that EMTALA education had been provided to ED and security staff on 5/26/23 - 7/26/23.

The above was confirmed by S1, S3, and S5 on 7/28/23 at 3:01 PM.