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Based on record reviews, policy reviews and patient and staff interviews and review of Campus Police Officer body cam video the hospital inappropriately discharged 1 (Patient 9) of 20 sampled patients prior to providing within the hospital's capabilities, a Medical Screening Examination (MSE) sufficient to determine whether an Emergency Medical Condition (EMC) existed, in accordance with the facility EMTALA policies. The failure to follow the hospital's policy and procedures for performing a MSE to determine an EMC has the potential to cause harm or death due to a delay in treatment. The total sample of 20 records, was taken from the central logs of patients presenting to the Emergency Department for a MSE from 3/1/21-9/30/21.

Findings are:

See also A 2406.

A. Review of facility policy titled "Emergency Medical Treatment and Transfer EMTALA" last revised 3/2017 states that The Hospital shall provide screening and stabilizing treatment or appropriate transfer within the scope of its abilities, as needed, to individuals with emergency medical conditions who come to the hospital for examination and treatment, regardless of diagnosis, financial status, race, color, national origin, or handicap in accordance with the he Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA does not apply to inpatients. Individuals on the hospital campus, who request emergency treatment, or appear to need emergency treatment, shall be directed to the emergency department. Hospital staff shall assist the individual as appropriate. The hospital campus includes parking garage, sidewalks, and driveways.

B. Review of the facility policy titled "Medical Screening Exam" last revised 6/2021 states A Medical Screening Exam is an examination and evaluation process consistently used by a qualified medical person, including ancillary services routinely available to the emergency department within the hospital's capabilities, to determine or diagnose whether or not the patient has an emergency medical condition.

C. Review of the facility policy titled "Leaving Without Being Seen (LWBS)" last revised 12/2019, identifies LWBS as any patient that leaves after registration but has not yet received a MSE by the ED attending Physician or Midlevel Provider. If ED staff is uncertain whether patient has left, the ED RN should make and document several attempts to locate patient in waiting area and/or areas adjacent to the ED--ie smoking area of ED drive.

D. In an interview with Patient 9 on 9/20/21 at 9:15 AM, Patient 9 revealed that after he arrived into the emergency department, the nurse checked him over quickly and told him that it would be awhile before he would be seen as there were a lot of patients and many needed attention before him, so he went to the waiting room/lobby. Patient 9 said when his significant other arrived, the lady at the desk said she couldn't stay with him until he was put in a room, so they went outside. Patient 9 said he walked around the grounds to have a few cigarettes while waiting to be seen. Patient 9 said he took off the collar (soft neck brace) the nurse put on him because it was hot and itchy, but he had his hospital ID wrist band on and a receipt for his belongings from hospital security. He indicated he walked around the outside of the hospital and was heading back to the ED to see if it was his turn to be seen and stopped to rest on the steps of the Doctor's Office building (on the hospital campus). Patient 9 stated that some security officers came and asked if he was waiting for a ride. He said he replied, why am I breaking the law, and they said he needed to get off the property, that he already had been seen. Patient 9 said he told them he had not been seen, "but they thought I was lying", I kept saying , YOU GOT THE WRONG GUY and we got into each others face and were yelling. All of a sudden someone from behind me grabbed me and threw me to the ground. I was put in handcuffs and then a police officer came and I told him, they had the wrong guy, I was going back up to the ED to see if it was my turn to be seen, and that I was in an accident, Patient 9 said the security officers said that he had already been seen and put him in the back of the police officer's car. Patient 9 said he never saw a doctor or anyone else but the nurse. Patient 9 said that eventually the security officers offered to take him back to the ED or to another hospital, but by then he didn't trust any of them to take him anywhere. Patient 9 said he walked until he found a ride to another hospital where he was examined. Patient 9 said he was exhausted physically and emotionally, "I know the other hospital did X-rays, talked to me, gave me medicine."

E. In an interview on 10/5/21 at 9:00 AM, ED RN B confirmed that she filled out the Left Without Being Seen form and stated that "a 3rd party heard the patient went outside and had an altercation with a significant other and security got involved. Then the 3rd party said security was taking the patient into custody." When asked to clarify the identity of the 3rd party, ED RN B stated, "I think it was the security officer in the ED." ED RN B then stated, "When I asked if we were going to see the patient the security guard told me the patient was going to be seen at another hospital." She indicated that when the form was filled out at 00:54 AM due to the information from the security officer in the ED he was taken off the "status board" [An electronic information board for the ED staff with all the patients that have been triaged and are either in an ED patient room or waiting in the waiting room/lobby to be called for their turn to be seen.], indicating he had not yet been called to be seen.

F. Interview with ED Nurse Manager RN C 10/4/21 at 3:45 PM confirmed the chart lacked documentation that Patient 9 received a MSE in accordance with our policies.

Based on record reviews, policy reviews and patient and staff interviews and review of Campus Police Officer body cam video the hospital inappropriately discharged 1 (Patient 9) out of 20 sampled patients, prior to providing within the hospital's capabilities, a Medical Screening Examination (MSE) sufficient to determine whether an Emergency Medical Condition (EMC) existed. The total sample of 20 records, was taken from the central logs of patients presenting to the Emergency Department for a MSE from 3/1/21 - 9/30/21. This failure has the potential for all patients presenting to the Emergency Department (ED) to be discharged prior to receiving a MSE which could result in harm or death due to delay in treatment. According to facility provided information the ED sees an average of 5477 patients per month.

Findings are:

A. Review of EMS documentation titled "Prehospital Care Report" on 8/30/21 at 8:52 PM shows Emergency Medical Technicians (EMT) - Paramedics were dispatched to a motor vehicle accident on a highway with the vehicle off the road. Further documentation showed that Patient 9 told the paramedics that he thought his car rolled over once and landed upright but was unsure because it all "happened so fast." The paramedics documented they assisted Patient 9 to the stretcher and arrived at the hospital at 9:45 PM and care was transferred to the emergency department (ED) nursing staff.

B. Review of Patient 9's 8/30/21-8/31/21 ED medical record showed the patient arrived by ambulance at 9:49 PM. At 9:55 PM the ED triage nurse documented that Patient 9 was restrained with a lap and shoulder belt when his vehicle ran off the road into dirt traveling at a high speed approximately 51-80 mph. Further documentation showed the patient did not require extrication, or that he lost consciousness, but was complaining of neck and shoulder pain. Following triage at 9:58 PM, the ED nursing staff placed Patient 9 in the waiting room to wait for a medical screening examination.

Approximately three hours later at 00:54 AM (8/31/21) documentation on the "Informed Refusal For Healthcare Services" form showed that Patient 9 refused examination and treatment. The reason for refusal documented on the form and signed by ED RN B and ED RN T showed "Pt was in an altercation and was detained." The space on the form for Patient 9's signature was blank.

C. In an interview on 10/5/21 at 9:00 AM, ED RN B confirmed that she filled out the Left Without Being Seen form and stated that "a 3rd party heard the patient went outside and had an altercation with a significant other and security got involved. Then the 3rd party said security was taking the patient into custody." When asked to clarify the identity of the 3rd party, ED RN B stated, "I think it was the security officer in the ED." ED RN B then stated, "When I asked if we were going to see the patient the security guard told me the patient was going to be seen at another hospital." She indicated that when the form was filled out at 00:54 AM due to the information from the security officer in the ED he was taken off the "status board" [An electronic information board for the ED staff with all the patients that have been triaged and are either in an ED patient room or waiting in the waiting room/lobby to be called for their turn to be seen], indicating he had not yet been called to be seen.

D. In an interview on 10/5/21 at 3:30 PM, ED Nurse Director stated, "It is not unusual for patients to wait outside of the ED. Since Covid we do not allow visitors in the lobby with the patient unless the patient is a child or the patient is confused, so many times the patients meet their family outside, sit in their car or go out and smoke. The triage nurse will go outside look around for the patient and call the patient's name, check the lobby, restrooms and conference room when it is the patient's turn for an examination.

E. In an interview on 10/5/21 at 9:30 AM, Campus Security Officer J (CSO J) revealed that he and a trainee CSO (CSO K) were patrolling the hospital grounds and parking lots. "We saw (Patient 9) walking around the campus and later saw the patient sitting on the steps of the south Doctor's Building on 44th Street, located at the bottom of the hill from the ED. CSO J stated, they radioed a description of the patient up to the CSO L who was working in the ED to find out if the patient had been seen. CSO L told me that a patient matching [Patient 9's] description had been dismissed. CSO J stated, "I got out of the patrol car and asked the patient if he was waiting for a ride? The patient replied, "Why am I breaking the law?" CSO J told the patient "no but you are on our campus and I am checking on you." CSO K was standing behind [Patient 9] while I was talking to him. [Patient 9] stood up and we were nose to nose. CSO J stated [Patient 9] "postured and had his fist balled up, but did not strike at me." "He turned and started going towards the ED and bumped me in the chest." CSO K then came up behind the patient and bear hugged him and put him to the ground. Our Supervisor CSO M arrived about then and "tried to get [Patient 9] to calm down, but he continued to struggle, so our supervisor pulled out his Bolah (a device that shoots out a wrap to secure a person)." "As soon as the patient saw that he quit struggling and went limp." "We then turned him over and cuffed him, waiting for the Campus Police Officer (PO G) to arrive." "[Patient 9] told us that he was going to the ER because he was in a motor vehicle wreck." "He did have a hospital wristband and a belongings bag with him." "When Campus PO G arrived we stood him up and put him in the back of his vehicle." "Our supervisor later went up to the ED to make sure [Patient 9] had been discharged, and he found out that [Patient 9] was still a patient and had not been discharged."

F. In a staff interview on 10/6/21 at 11:30 AM, CSO L, the campus security officer working inside the ED (on 8/30/21, stated that CSO J called with [Patient 9's] description. "When (CSO J) called I asked if this guy had a child with him. He said, No. I said then it might not be the same guy. I believe [Patient 9] was mistaken for another black gentleman that left with his son."

G. Review of Campus Police Officer G (PO G) 8/31/21 body cam video from 12:26:37 AM - 1:27:00 AM revealed that PO G arrived to the incident at 12:28:48 and found Patient 9 in handcuffs sitting on the ground with Campus Security Officers (CSO) around him. PO G's body cam revealed at 12:33:06 AM, Patient 9 told PO G "I am going to go back to the Emergency Room." PO G replied, "No, you're not, you got discharged." Patient 9 stated, "You got the wrong one, I am waiting on the hospital." Patient 9 indicated the wait was long and he went outside for a cigarette and walked around because you can't smoke at the hospital. Patient 9 again stated at 12:34:35 AM, "I need to get checked out, I was in a rollover crash." At 12:52:38 AM, PO G told Patinet 9, "The Emergency room doesn't want you back, you are not on their list to get in." Patient 9 told PO G, "I signed everything to be seen, I called my insurance on the phone it was 9 something. I had to wait, it's a hospital Man, they told my lady they could not have visitors in the waiting room. The ambulance brought me, I didn't do anything! I just walked around having a cigarette. It became hostile, I'm sore man, my arms are bleeding from where they were dragging me on the ground." At 1:06:17 AM Campus Police Sergeant H arrived and asked Patient 9 if he wanted to go to a different hospital and be seen, that she would give him a ride. Patient 9 said "NO, I already got a neck injury, pain and now this. I just came down here where it is quiet." At 1:11:03 AM, PO G asked Patient 9 again, do you want to go to the ER or to a different hospital? "No, am going to walk, I got discriminated against." Campus Police Sergeant H took his ticket (receipt for his belongings) to security at the hospital and returned them to the patient. At 1:26:57 AM Patient 9 was released on the 44th street (hospital campus) and the patient walked away.

H. In an interview with Patient 9 on 9/20/21 at 9:15 AM, Patient 9 revealed that after he arrived into the emergency department, the nurse checked him over quickly and told him that it would be awhile before he would be seen as there were a lot of patients and many needed attention before him, so he went to the waiting room/lobby. Patient 9 said when his significant other arrived, the lady at the desk said she couldn't stay with him until he was put in a room, so they went outside. Patient 9 said he walked around the grounds to have a few cigarettes while waiting to be seen. Patient 9 said he took off the collar (soft neck brace) the nurse put on him because it was hot and itchy, but he had his hospital ID wrist band on and a receipt for his belongings from hospital security. He indicated he walked around the outside of the hospital and was heading back to the ED to see if it was his turn to be seen and stopped to rest on the steps of the Doctor's Office building (on the hospital campus). Patient 9 stated that some security officers came and asked if he was waiting for a ride. He said he replied, why am I breaking the law, and they said he needed to get off the property, that he already had been seen. Patient 9 said he told them he had not been seen, "but they thought I was lying", I kept saying , YOU GOT THE WRONG GUY and we got into each others face and were yelling. All of a sudden someone from behind me grabbed me and threw me to the ground. I was put in handcuffs and then a police officer came and I told him, they had the wrong guy, I was going back up to the ED to see if it was my turn to be seen, and that I was in an accident, Patient 9 said the security officers said that he had already been seen and put him in the back of the police officer's car. Patient 9 said he never saw a doctor or anyone else but the nurse. Patient 9 said that eventually the security officers offered to take him back to the ED or to another hospital, but by then he didn't trust any of them to take him anywhere. Patient 9 said he walked until he found a ride to another hospital where he was examined. Patient 9 said he was exhausted physically and emotionally, "I know the other hospital did X-rays, talked to me, gave me medicine."