HospitalInspections.org

Based on review and interview, the physician failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department.

Given the patient's state of confusion and agitation, poor memory, poor ability to focus, and irrational thinking, Patient #1 lacked capacity to refuse or be denied medical care. There was no discussion of risks of not receiving care. An appropriate medical screening examination was not completed to determine whether or not an emergency medical condition exists

Refer to A2406.

Based on review and interview, the physician failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department.
Given the patient's state of confusion and agitation, poor memory, poor ability to focus, and irrational thinking, Patient #1 lacked capacity to refuse or be denied medical care. There was no discussion of risks of not receiving care. An appropriate medical screening examination was not completed to determine whether or not an emergency medical condition exists.

Findings:

Facility #1, Emergency Department (ED) sees an average of 1800 patients a month, they have 12 beds, 1 of which is a trauma bay. They are a designated Trauma IV.

Central Log: The patient's name appears on the Emergency Room log on 09/15/2023 at 10:14 AM for "Rib/trunk pain-swelling" with an ESI Level 3.

Patient #1 was a 54-year-old, female with a history of COPD (chronic obstructive pulmonary diseases) (patient stated), Emphysema (patient stated), Hypertension (patient stated), Mycoplasma infection (Medical), PTSD (post-traumatic stress disorder) (patient stated). Patient arrived at Facility #1 via EMS on 9/15/2024 at 10:14 AM for complaints of "I broke 4 ribs". EMS Care Record documented "Behavioral/psychiatric episode" with signs and symptoms "Strange and inexplicable behavior (Primary), injury to chest".

EMS unit 635 was dispatched to Patient #1's address for a fall. "EMS responded to the scene with lights and sirens using due regard without incident. EMS arrived on scene to find a female patient sitting on the stairs outside.

The patient had a fast, strong, regular radial pulse with pink, warm, and dry skin. The patient was A&Ox4 (alert and oriented to person, place, time and situation) and GCS (Glascow Coma Scale) of 15. The patient was making strange motions with her arms and hands. The patient was telling story's that could not have happened. The patient stated she tripped in a hole in her kitchen floor and landed on the broom stick. EMS asked the patient if she landed on the pointed end of the broom stick and the patient stated she hit the corner of the table. EMS asked the patient which was it, and the patient stated "yeah". The patient would not tell EMS what she landed on. EMS did not see any deformities or wounds to any aspect of her body. The patient stated she was in severe pain in her right anterior chest. The patient stated, "I broke 4 ribs, 5/8th of an inch away from my heart". The patient kept moving her arms around. When asked if the patient took something the patient stated she did not. The patient stated there was people in her yard dancing is the reason why she fell. The patient did not appear to be in any distress or pain. The patient got mad and started yelling because she said someone was laughing and making fun of her. EMS preformed a Cincinnati stroke screen on the patient to find no abnormalities. The patient stated she wants to go to ____(Facility #1).

EMS assisted the patient to a standing position and onto the stretcher without incident. EMS raised both rails and secured all straps. EMS transported the patient to the ambulance via stretcher without incident. EMS loaded the patient into the back of the ambulance via stretcher with the stretcher locked into the locking mechanism.

EMS obtained a set of vitals (BP 138/62, Pulse, 126 R, RR 20 R, SPO2 95 RA, BG 129, Temp 98.7 F, Pain 0/10). The patient stated, "I absolutely do not want any other treatments". EMS explained the risks to the patient and the patient still refused. EMS told the patient if she changes her mind to let EMS know and the patient stated okay. EMS obtained a signed refusal by the patient EMS transported the patient to the ER via ambulance without incident. EMS notified the receiving facility via Pulsara. EMS monitored the patient throughout transport to find no patient changes. The patient was still moving her arms in all motions. The patient stated she was driving a stick shift car. The patient then was looking outside and making sure people was pulling over for a funeral progression (there was no funeral progression). The patient stated she was still having chest pain on her right side. EMS still did not see any wounds or deformities. The patient still did not appear to be in any distress or pain. EMS obtained another set of vitals (BP 100/63, Pulse 128 R, RR 20 R, SPO2 97 RA, Pain 0/10).

EMS arrived at the ER and transported the patient inside via stretcher without incident. EMS moved the patient over from the stretcher to the ER bed via draw sheet method. EMS gave a patient report to RN and obtained all signatures. EMS turned over patient care to ER. EMS unit 635 returned back to service and available for call."

Facility #1 ED Triage on 9/15/2023 at 10:16 AM

Systolic BP: 172 mmHg
Diastolic BP: 68 mmHg
Mean Arterial Pressure: 103 mmHg
Heart Rate: 112 bpm
Respiratory Rate: 20 breaths/min
Sp02/Pulse oximetry: 95 %
OXygen Delivery: Room air
Dosing BSA-Mosteller: 1.87 m2
Height: 167 cm
Dosing Weight: 75 kg
Dosing BMI: 27
Mentation Perfusion Hydration Assessment: Alert, Awake, Pink, Warm ESI Level 1: No
ESI Level 2: No
ESI Level 3: Many
Vital Signs ESI: No
Recommended ESI Level: 3

Nursing Note 9/15/2023 at 10:30 AM by Staff #7, ER, RN

"Nursing Note: Patient wandering halls and verbally yelling profane language at nurses. Asked to return to her room and patient proceeded to pull her shirt up exposing her breasts. Security called."

Nursing Note 9/15/2023 at 10:40 AM by Staff #7, ER, RN

Nursing Note: "________(Staff #8, ED, MD) attempting to visit with patient but patient being verbally disruptive in hallway and again pulling her shirt up flashing everyone. _______(Staff #8, ED, MD) asked patient not to do so and that to be aware that there are very sick patients in here and she needed to return to her room. Patient proceeded to go up to patient in hallway 1 and put her breast in her face. At this point security went to call PD (police department) and patient was escorted out of ER doors."

ED Physician Note 9/15/2023 at 10:45 AM by Staff #8, ED physician

CHIEF COMPLAINT:
"C/O broken ribs close to her heart. Patient does not relate incident. States "broken, glasses, shield, flew, just put it together." Exhibits flight of ideas."

MEDICAL DECISION MAKING:
"Patient was repeatedly walking up into the nursing station, was not following instructions for back into her room. Would not cooperate with staff for the full set of vital signs, refused a temperature check. Security guard was called and was in the hallway, patient was shouting and cursing at the security guard as well as staff. I saw patient in the hallway, discussed with patient that she is disturbing other patients here, I asked that if she cannot go back to room and follow instructions, and stop exposing herself, that she cannot stay here. Patient has been lifting her shirt up and showing her breast to staff as well as to other patients who was in the hallway as well. I asked her again that if she cannot behave appropriately then she will have to leave. We will also call police for indecent exposure as well. Patient started mocking us when we discussed that this is disturbing other sick patients with her behavior. Patient states that she would rather leave. She chose not to behave, she continued to show her breasts as she was walking out, and to make sure that she wants her breast to be seen on camera. Patient had clear speech, no facial droop, she was ambulating unassisted without any difficulties moving all 4 extremities, she did not look in any distress. She was actually laughing at points and mocking the staff as well. She did not exhibit any signs of self-harm. Normal sats on room air at 95%, normal respiratory effort at 20. She was slightly tachycardic at 112 but she was also easily riled up. Blood pressure slightly elevated 172/68. She would not let us check it for temperature.

No impressions/plan, pt choose to leave as she does not want to behave properly."

Facility #1 Incident Report with attached POLICE REPORT 9/15/2023:

Staff #9, Security Officer: "A patient started acting up in the ER and had to be removed. We had her trespassed. However, she snuck back in the ER and we had to call the police on her again, and had her taken off the property. _______ (Patient #1) was coming at nurses and security in a threatening manner. She was also flashing the other patients and visitors."

911 was called on 9/15/2023 at 10:52 AM by Staff #9

An interview with Staff #6, ED physician 6/04/2024 at 1:10 PM stated: "If a patient is not homicidal or suicidal and they are medically stable, we cannot legally hold someone because they are acting strange. At that point we must let them leave if that is what they choose to do. If they are homicidal or suicidal, we will call the judge for a temporary hold until we can get the patient the care they need and keep them safe."