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Based on policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#1 and #22) of 30 Emergency Department (ED) and Labor and Delivery records reviewed.

Findings included:

Review of the hospital's policy titled, "EMTALA," reviewed 03/24/23, showed:
All persons presenting to the ED are entitled to a MSE to determine whether or not an EMC exists. A MSE is the initial and on-going evaluation of a patient based on their presenting condition and is conducted by a qualified provider. The MSE includes the history, physical examination, appropriate testing, appropriate documentation, and evaluation of the patient. The evaluation must be within the capabilities of the hospital, utilizing facilities routinely available to the ED and the use of on-call physicians as appropriate, to determine whether a patient has an EMC. All patients shall be monitored, and their vital signs recorded based on their triage (process of determining the priority of a patient's treatment based on the severity of their condition) category. Patients presenting with psychiatric (relating to mental illness) disturbances are considered to have an EMC and should receive a mental health (MH) screening in addition to their medical screening. The MH screening should be utilized to determine the risk of harm to self or others and the appropriate disposition and/or transfer based on the patient's condition. Patients must be protected and prevented from injuring themselves or others during transfer. The time of triage, category of triage, time of arrival, time of placing in a treatment room, time of the provider's MSE, along with the time of call to and the arrival of any on-call provider should be noted. Patients should receive appropriate and necessary medical care to remove the risk of deterioration of their condition prior to discharge or transfer.

Review of the hospital's policy titled, "ED - Initial Suicide (to cause one's own death) Assessment and Observation," revised 02/13/23, showed:
- Patients presenting to the ED will be initially screened through ED triage (process of determining the priority of a patient's treatment based on the severity of their condition).
- Nursing will utilize the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) short version tool to assess the patient for suicide risk.
- Questions required for all patients include, have you wished you were dead or wished you could go to sleep and not wake up; have you had any thoughts of killing yourself; and have you ever done anything, started to do anything or prepared to do anything to end your life?
- Upon assessment of the patient, providers will enter a communication order if their clinical judgement deems the suicide risk level to differ from the C-SSRS recommendations.
- Nursing will implement an observation level based on the new order.

Review of the hospital's policy titled, "Patient Elopement (when a patient makes an intentional, unauthorized departure from a medical facility) Procedure," revised 04/08/19, directed staff to observe, follow or attempt to contain patients to the extent that the safety of all persons is maintained. In the event of an elopement notify the administrator on-call and complete an event report.



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Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for two patients (#1 and #22) of 30 Emergency Department (ED) records reviewed from 10/01/24 to 04/02/25. This failed practice had the potential to cause harm to all patients who presented to the ED.

Findings included:

Review of the hospital's policy titled, "EMTALA," reviewed 03/24/23, showed:
All persons presenting to the ED are entitled to a MSE to determine whether or not an EMC exists. A MSE is the initial and on-going evaluation of a patient based on their presenting condition and is conducted by a qualified provider. The MSE includes the history, physical examination, appropriate testing, appropriate documentation, and evaluation of the patient. The evaluation must be within the capabilities of the hospital, utilizing facilities routinely available to the ED and the use of on-call physicians as appropriate, to determine whether a patient has an EMC. All patients shall be monitored, and their vital signs recorded based on their triage (process of determining the priority of a patient's treatment based on the severity of their condition) category. Patients presenting with psychiatric (relating to mental illness) disturbances are considered to have an EMC and should receive a mental health (MH) screening in addition to their medical screening. The MH screening should be utilized to determine the risk of harm to self or others and the appropriate disposition and/or transfer based on the patient's condition. Patients must be protected and prevented from injuring themselves or others during transfer. The time of triage, category of triage, time of arrival, time of placing in a treatment room, time of the provider's MSE, along with the time of call to and the arrival of any on-call provider should be noted. Patients should receive appropriate and necessary medical care to remove the risk of deterioration of their condition prior to discharge or transfer.

Review of the hospital's document titled, "Medical Staff Bylaws," revised 10/03/23, showed the provider must complete and document a medical history and physical examination for each patient. Appropriate, timely, and continuous care of the patient shall be provided, including a complete and accurate medical record.

Review of the hospital's policy titled, "ED - Initial Suicide (to cause one's own death) Assessment and Observation," revised 02/13/23, showed:
- Patients presenting to the ED will be initially screened through ED triage (process of determining the priority of a patient's treatment based on the severity of their condition).
- Nursing will utilize the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) short version tool to assess the patient for suicide risk.
- Questions required for all patients include, have you wished you were dead or wished you could go to sleep and not wake up; have you had any thoughts of killing yourself; and have you ever done anything, started to do anything or prepared to do anything to end your life?
- Upon assessment of the patient, providers will enter a communication order if their clinical judgement deems the suicide risk level to differ from the C-SSRS recommendations.
- Nursing will implement an observation level based on the new order.
Review of the hospital's policy titled, "Patient Elopement (when a patient makes an intentional, unauthorized departure from a medical facility) Procedure," revised 04/08/19, directed staff to observe, follow or attempt to contain patients to the extent that the safety of all persons is maintained. In the event of an elopement notify the administrator on-call and complete an event report.
Review of Patient #1's "Police Report Arrest Number 8063217," dated 04/07/25 at 8:32 PM, showed Patient #1 was placed under arrest while standing near the ambulance bay. She eloped a 96-hour hold.

Review of Patient #1's medical record showed:
- On 10/04/24 at 6:00 PM, a 37-year-old female presented to the ED and requested medication refills, she was anxious, incoherent and rambling to herself.
- Her past medical history included schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly), methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) abuse and substance induced mood disorder (a change in the way you think, feel, or act, caused by taking or stopping a drug).
- With word salad (confused or unintelligible mixture of seemingly random words and phrases) and tangential speech (a type of speech disorder in which each of a series of thoughts seems less closely related to the original thought than the one before it), she requested clonazepam (medication used to treat anxiety) for her constant movements.
- She had erratic body movements and very bizarre behavior; she constantly changed the subject.
- Methamphetamine use/induced psychosis was suspected, and she was not safe to herself or the public.
- She was at risk of deteriorating.
- At 6:19 PM, she denied thoughts of harming herself in the last three months. Questions one, two and six of the C-SSRS were not completed.
- At 7:40 PM, she refused to enter an ED room and stormed out of the ED. She was found by security on the street, the local police department was notified, and she was taken into police custody.
- Due to concern that she was at risk of harming herself and others, 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) paperwork was sent to the Sheriff's office.
- The 96-hour hold paperwork showed she presented to the ED acting erratically with tangential speech. The ED provider believed she was having a psychotic episode and was unsafe to herself and the public. She needed a psychiatric evaluation and treatment.

During an interview on 04/03/25 at 3:18 PM, Staff W, ED Medical Director, stated that he expected staff to follow their Crisis Prevention Institute (CPI, a type of training where staff learn to safely defusing violent behavior and safe physical holds to restrict a person's movement) training and call the response team to prevent elopements. The response team consists of security and law enforcement. If a suicidal patient attempted to elope, he expected the staff to attempt to de-escalate the situation, but not to restrain the patient. If the patient was on hospital property, he expected security to place a hold on the patient. Staff should follow the hospital's policies and procedures.

During a telephone interview on 04/04/25 at 9:33 AM, Staff X, Physician Assistant (PA, a type of mid-level health care that can serve as a principal healthcare provider), stated that when a patient was deemed unsafe to themselves or others, he expected staff to prevent the patient from eloping. To avoid injury from a combative patient, the staff could call security for support. He expected the triage nurse to complete the suicide assessment screening according to the hospital's policy. All staff should follow the hospital's policies and procedures.

During an interview on 04/03/25 at 1:43 PM, Staff O, ED Manager, stated that he expected staff to do everything they could to prevent elopements without placing themselves in harm's way. All staff received CPI training, though classes were only held "a couple of times a year" for new staff. If a patient was a suicide risk, a one-to-one (1:1, continuous visual contact with close physical proximity) sitter was to be placed. He expected the security officers to assist with de-escalation. Patient #1 was "difficult" but not physically assaultive. The security officer declining to place Patient #1 in a hold upon the charge nurse's request did not meet his expectations. The security officers should assist when needed. He did not understand why law enforcement did not return the patient to the ED. Staff should follow the hospital's policies and procedures. He was not notified of the elopement until the following day, not at the time of the incident. Suicidal patients should not be allowed to elope from the hospital. There was no follow up or additional education with staff in response to this event.

During a telephone interview on 04/03/25 at 12:14 PM, Staff T, Registered Nurse (RN), stated that when a patient was determined to be a risk to themselves a 1:1 sitter was placed. When the triage nurse determined a patient needed a psychiatric evaluation, the patient was immediately taken to an ED room and evaluated by the provider. The C-SSRS determined the necessity for a 1:1 sitter. If the provider's assessment differed from the C-SSRS an order was written for the appropriate level of observation. When Patient #1 eloped, security was notified and found the patient on the property near a busy intersection. She was taken to the patient by security and attempted to convince her to return to the ED. She wanted the patient out of the street due to the danger. Staff T asked security to assist with getting the patient inside, but the security officer refused to place the patient in a hold. Security called local law enforcement, and the patient was taken into custody. The hospital needed to ensure suicidal patients did not elope. Patient #1's elopement could have been prevented. No follow-up or education was received from leadership in response to this event.

During an interview on 04/03/25 at 2:00 PM, Staff DD, Quality and Patient Safety Director, stated that an event report was not completed in related to Patient #1's elopement.

Review of Patient #22's medical record showed:
- On 09/08/24 at 7:08 PM, a 59-year-old male presented at the ED with complaints of generalized fatigue (weakness or tiredness) and malaise (body weakness or discomfort). He complained of vomiting and diarrhea for the last week without abdominal pain. He had a mild productive cough and felt like he had increased shortness of breath over the last three days. He denied any fever.
- His medical history included chronic kidney disease (CKD, ongoing, gradual loss of kidney function), atrial fibrillation (A-fib, an irregular, often rapid heartrate that commonly causes poor blood flow), chronic ( long-term, ongoing) pain, depression, high blood pressure, pleural effusions (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), peri-rectal (the rectal space which is the last part of the large intestines where stool is stored before leaving the body) abscesses (a collection or pocket of thick fluid cause by an infection),and sepsis (life threatening condition when the body's response to infection injures its own tissues and organs), along with multiple co-morbidities ( the presence of one or more medical diagnoses existing along with a primary condition).
- At 7:16 PM, an electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) was obtained and indicated a septal infarct (suggests a possible heart attack affecting the septum [the wall separating the heart's chambers] at an unknown time in the past, potentially requiring further testing for confirmation and to determine the extent of damage).
- At 7:42 PM, his vital signs (VS, Vital signs (VS, measurements of the body's most basic functions: blood pressure [BP] normal between 90/60 and 120/80; pulse/heartbeats [HR] normal 60 to 100 per minute; respiration rate [RR] normal 12 to 20 breaths per minute; and body temperature normal 97.8 to 99 degrees) were documented as a BP of 142/97, with a mean arterial pressure (MAP, is a key indicator of organ perfusion, with a normal range typically between 70 and 100 mmHg) of 112, a RR of 23, and a HR of 91.
- At 7:49 PM, the laboratory results showed a white blood cell (WBC, the number of white blood cells [infection fighting cells] in the blood, the normal range between 4.8-10.8) count of 17,600, and an elevated blood urea nitrogen (BUN, test that specifies kidney function, normal range between 9 and 23) of 39.
- At 7:51 PM, the chest x-ray (test that creates pictures of the structures inside the body-particularly bones) showed hyperaerated lungs (a condition where the lungs expand beyond their normal size due to trapped air, often seen in people with COPD which leads to difficulty breathing).
- At 8:30 PM, his VS were BP 149/67 with a MAP of 89, HR 87 and RR 52.
- At 9:00 PM, his VS were BP 106/59 with a MAP 76, HR 87 and RR 32.
- At 9:02 PM, COVID-19 (highly contagious, and sometimes fatal, virus) and influenza (highly contagious condition affecting the respiratory system) tests were negative.
- At 9:30 PM, his VS were BP 105/57 with a MAP 72, RR 32 and HR 85.
- At 10:32 PM, Staff U, ED Physician, documented the laboratory results were re-assuring, other than the elevated WBC's. Based on Patient #22's history of COPD antibiotics and steroids were ordered.
- At 10:44 PM, his VS are BP 91/54 with a MAP 65, RR 24 and HR 90.
- His temperature was never recorded.
- At 11:38 PM, he was discharged home.

Review of Patient #22's medical record dated 09/14/24, showed:
- At 11:05 AM, he presented at the ED with complaints of constipation and rectal abscess.
- At 11:11 AM, his VS were BP 129/72, HR 115, RR 22, T 98.0 and SAO2 95%.
- At 11:50 AM, an abdominal and pelvis computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan showed peri-rectal and perianal (situated in or affecting the area around the anus) abscesses.
- At 1:29 PM, he was admitted to the hospital to the general surgery department.

During an interview on 04/03/25 at 3:20 PM, Staff W, ED Medical Director, stated with a MAP greater than 65, he would have liked to know whether the patient had a fever or not. Additional assessment, including a C-reactive protein test (CRP, a test that measures the amount of CRP in the blood to detect inflammation either for acute conditions or to monitor chronic conditions) and calcitonin (a hormone that regulates the amount of calcium in the blood, an elevated level can indicate kidney problems) level would have been helpful. He did not care for Patient #22 and he could not comment.

During an interview on 04/03/25 at 2:35 PM, Staff U, ED Physician, stated she typically did not order blood cultures based only on an elevated WBC count. The elevation could be related to inflammatory issues from COPD exacerbation (increase in symptoms). Patient #22 was alert and oriented. He stated that he felt better after the breathing treatments and steroids. In hindsight, she would have ordered intravenous fluids to replenish his fluid volume.

During an interview on 04/03/25 at 1:45 PM, Staff O, ED Manager, stated the hospital does not have a standard sepsis protocol. Orders are often placed based on the nursing assessment. He expected nurses to report any change in condition to the physician. He was surprised that Patient #22's decrease in BP was specifically documented in the medical record. With the drop in BP, he would have expected blood cultures or a lactic acid level. Nursing staff should document full sets of VS upon admission.

During an interview on 09/07/25 at 4:51 PM, Staff V, ED Charge Nurse, stated that the temperature should have been taken and monitored. Nursing should documenta a complete assessment. Had she been aware of Patient #22's decreasing BP, she would have advocated for additional testing and monitoring.


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