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Based on interview and record review, the hospital was not in compliance with §42 CFR 489.24, Special Responsibilities of Medicare Hospitals in Emergency cases, in that patient #1 who arrived in the facility via ambulance was not provided a complete Medical Screening Exam (MSE) on her ED (emergency department) visit on June 1, 2021.

Cross refer to Tag 2406.

Based on interview and record review, the hospital failed to provide an appropriate Medical Screening Examination (MSE) to patient #1 who presented in the emergency department (ED) via ambulance on June 01, 2021, citing one of twenty one patients.

Findings included:

On 06/01-02/2021 Patient #1's medical screening exam was in process. The patient was seen upon arrival to the hospital's ED, however there was a delay in completion of the medical screening exam because the patient was able to elope several times during the visit. On the last elopement, the patient was arrested and taken into custody by the police and taken to jail. At the time the patient was taken into custody, the patient's physical exam and workup were unremarkable, however the patient was not fully stabilized and had not been medically cleared.

Patient #1's Medical Record
06/01/2021 at 2237. Room 06.
Patient Patient #1 was an " ...Approximately 46-year-old female who presents to the ER via EMS [with a local Police Department] for altered mental status. PD was called out by an apartment complex after patient was found in a maintenance room acting odd. PD states patient has not communicated with them. Patient was noted to have a large bag of handwritten notes, which appear to have delusional messages. Unknown if patient has any psychiatric history or medical history. Patient not speaking here in the ER ..."

Patient #1's past medical history, surgical history, family history, smoking history, and social history was unable to be obtained due to Patient #1 being nonverbal.

Physical Exam
Patient #1 was awake, alert, and in no acute distress. Her head appeared to be atraumatic. Her pupils were equal, round, and reactive to light. Her conjunctiva was clear. Her membranes were moist. Her abdomen was soft and non-tender. She had no gross abnormality. Her skin was warm/dry and without rashes. Her neck was atraumatic and supple. Her chest was atraumatic with normal breath sounds. No respiratory distress. Her heart rate was normal with a regular rhythm. She had no motor deficits, no sensory deficits, and her cranial nerves II-XII were intact. The patient refused to answer questions.

Laboratory Tests
06/01/21 at 2255. Chemistry, Hematology, Toxicology, and Urine tests.
Her toxicology test results were negative except for Alcohol, Quantitative was <3 (0-80 mg/dl). Hematology was normal. Chemistry had some elements that were slightly outside of normal but with no concerns. Urine was normal except for a trace of protein.

Radiography
Physician's Order: CT Head with no contrast
to be read by Radiologist and reviewed by ED physician. The order was not carried out due to the patient's elopement and arrest.

Re-Evaluation
06/02/21. " ... 46-year-old female who presented to the ER for altered mental status. On arrival to the ER patient awake, alert, not speaking and uncooperative. Patient came with large bag full of handwritten notes, with obvious delusional messages. Patient with normal vital signs. Labs are unremarkable. UDS is negative. Patient eloped from her ER room, PD was notified ... Condition Stable ... Primary Impression: Altered mental status ..." Disposition Decision time 0136. Patient eloped from her ER room.

ED Nurse's Notes.

06/01/21-2235 PM. Arrival Date/Time
2235 PM. Triage was started.

Subjective Assessment. 06/01/21. 2235. " ...Brought in by EMS from apartment building after management called after finding her in their riser room. Patient refuses to answer questions or speak aloud. EMS reports patient refused to comply with vital signs en route and frequently tried to escape. Patient found with soiled belongings and notes written in crayon describing herself as a Christ figure and an 'Elite' ..."

Objective Assessment. " ...Patient awake, nonverbal, airway patent & midline, RR even & unlabored, skin warm, dry, color WNL for race, cap refill 2> seconds ... belongings soiled and moist ..."

Suicide screening. Unable to assess.
Finger stick blood glucose prior to arrival: 140's
BMI calculated: 20.4
Chief Complaint: Behavioral Health Related
Expected outcome of chief complaint: Stabilized/maintained
Patient is Homeless.

Violence/Aggression Screening
BROSET screening completed. BROSET risk type: Small.

Right peripheral IV line inserted 06/01/21 at 2235.
IV line removed by patient 06/02/21 at 0100.

Vital Signs. 06/01/21. 2331. B/P-128/74, Pulse-92, Respiration rate-22. Oxygen level on room air-98%.

ED Nurse's Notes
06/01/21. 2306. " ... PT not answering any questions, obeying commands, or opening eyes. PT brought in by EMS with a local PD, unknown how long PT has been like this. Per a local PD, PT has been seen on security cameras at this hotel she was brought in from for the past 2 days ..."

06/02/21. 0009. " ...Pt was out of ED lobby without clothes. PPD provides sheet for patient to cover self. This RN assists patient by ambulation with assistance back to ED room 6. Patient has a smirk on face and appears to be feeling happy; however, patient does not respond to questions but does move her head ..."

06/02/21. 0101. " ...PT wondering halls after dressing self, displaying hand written signs stating she is 'Hearing impaired and vision impaired and that it is late and she needs to go' PT redirected back to room 6 and informed that she needs to finish being checked out and evaluated before being able to leave. Pt still not verbally answering questions ..."

06/02/21. 0140. "PT got out of bed and walked out of department. a local PD notified and followed PT out of department ..." Patient left at 0145.

Hospital's Incident Report by the Security Department
Reporting Officer #6
Defendant: Patient #1

06/02/21 at 3:51 AM. Author: Officer #8
Officer #8 was coming inside from a helicopter, and ran into a patient leaving. Patient #1 was trying to leave while under the influence. She came from the ER in nothing but a sheet. Officer #8 tried to take the patient back to her room. The patient at first refused, then Officer #8 called local PD Officer #9 to help. Officer #9 came and grabbed the patient, both security officer and a local PD officer waited for staff. While waiting Patient #1 began to urinate on the floor. Environmental Services was called to come clean it up. Officer #8 and staff got the patient back in the room.

After the patient got in the room, the patient tried to leave again 4 more times. Officer #8 asked if the patient was on a legal hold. The patient was not on an OPC (order of protective custody). Officer #8 "made the judgment call to staff that if the patient leaves again a local PD would come to arrest them for PI (Public intoxication)." Officer #8 saw the patient leave and had local PD Officer #9 call for a patrol car. Local PD Officer #6 who arrested the patient, arrived. The patient was subsequently arrested.

Police Department Incident/Arrest Report.
"Offense Location/Date: 3901 W 15th St, Plano, Collin County, Texas, on the 2nd day of June, 2021 at 0109 hours."
On Tuesday, June 2, 2021 at approximately 0109 hours PD Officer #6 was operating a clearly marked Police Tahoe. He responded to the hospital located at 3901 W 15th St, Plano, Collin County, Texas in reference to local Police Officer #9 requesting for an additional officer/officers at the location in reference to Patient #1 who had been admitted to the location attempting to leave. Local Police Officer #10 and Police Officer #11 also responded to the location to assist.

PD Officer #6 had earlier dealt with the Patient #1 under incident #21-090220 which he had responded to local apartments in reference to a possible homeless subject sleeping in the fire room at approximately 2150 hours on 06/01/2021. The officer made contact with the unknown female subject who was sleeping on the floor of the fire room. He attempted multiple call outs to her however she was unresponsive to his verbal commands and questions. He observed her eyelids to be constantly fluttering during this time.

Due to the totality of the circumstances, a local FD (fire department) transported Patient #1 to the hospital where she was placed into the care custody and control of the staff at the location to be medically evaluated..

PD Officer #6 arrived to assist PD Officer #9 at 0116 hours in the parking lot area to the west of the hospital. PD Officer #6 was advised by PD Officer #9 that Patient #1 had attempted to leave the hospital about five times including once with only shoes on before she was brought back. A small empty bottle was discovered among her property and Patient #1 had also urinated on the ground while at the hospital. PD Officer #6 stated he observed Patient #1 displaying the same signs as he had dealt with her earlier. At that time, PD Officer #6 detained Patient #1 with cuff wrist restraints (double-locked to prevent tightening) for Public Intoxication.

PD Officer #11 searched Patient #1's property before her arrest and located a Texas Class C driver's license (DL) with Patient #1's name and date of birth 12/09/1980. He was able to match the picture on the DL to that of Patient #1 at hand. A check of Patient #1 through dispatch by PD Officer #9 also yielded an outstanding warrant for her arrest.

Fire-Rescue Patient Care Record
Incident #21-15748
Date: 06/01/2021.
Patient First Name: Patient
Patient Last Name: Patient
Age: 35 years (estimated)
Primary impression: Mental disorder
Complaint: "No complaints/will not talk to EMS."
Signs & Symptoms: "No Patient Complaint-No Complaints or injury/illness noted"
Narrative
" ...Medic 12 and Engine 5 AOSTF an approximately 35 year old female patient with a cc of a possible mental disorder. a local PD requested EMS to the location to asses Pt. PD stated to EMS that according to the apartment complex personnel the Pt has been living in the fire riser room in one of the buildings for approximately three days. Pt was found standing next to fire riser room non verbally with a GCS of 11, with a local PD next to Pt. Pt's v/s, assessment, and treatment is as noted in report. Pt had no trauma noted by EMS, Pt was nonverbal to EMS and refused to let EMS assess BP. Pt was ambulatory to EMS stretcher, Pt was secured to ambulance stretcher, and moved to the back of unit, with assistance from Engine 5 crew members, without incident..." Patient #1 was transported to the hospital without incident. At the hospital patient care and report were transferred over to the emergency department staff RN without incident. Patient #1 refused to sign the report.

Interviews
During an interview on 09/28/21 at 2:15 PM with RN (registered nurse)-ED Director #7 she said when patients present with behaviors that could result in harm to the patient or others they utilized an off-duty local Police officer, hospital security, and/or paramedics who are used as sitters.

During a telephone interview on 09/30/21 at 1:01 PM with RN #4 he said Patient #1 was brought in by the paramedics who said she had not been cooperative and was nonverbal. She had been found in a riser room at an apartment complex where she appeared to have been staying. She had a large bag with her. Staff asked if they could look inside the bag and she shook her head yes. There were a lot of handwritten notes inside. The notes indicated she was Christ or something like that. They did not empty the bag and did not find any personal identification. She attempted to leave several times. Mostly going to the secretary and handing her handwritten notes. One note said she couldn't see or hear well. When she was spoken to it appeared she was giving direct eye contact and was understanding what was being said. When she was spoken to she appeared to hear. She had an MSE and labs were drawn. A CT of her head had been ordered but it was thought she left before it could be completed. RN #4 thought she had a sitter that night but couldn't remember for sure. The police didn't talk to him before arresting the patient. Her vital signs were stable and her level of consciousness seemed normal.

During a telephone interview on 09/30/21 at 2:10 PM with Physician #3 she said Patient #1 was entered into the system as a Jane Doe because the patient was nonverbal and they didn't know her name or date of birth. She was calm and cooperative and restraints were not warranted even though she attempted to elope several times. She had a big sack of psychotic notes. Physician #1 attempted to take a medical history but the patient wouldn't answer her questions. She assessed the patient physically and ordered lab work, CT of the head, and an IV. Patient #1's vital signs were stable and her lab work wasn't concerning. She had some alcohol detected in her blood. She left before the CT of her head was done. She was medically stable when she left. Physician #3 planned to call Behavioral Health to fast track her to a behavioral health facility after she had her CT and was medically cleared. The police did not talk to Physician #3 before arresting the patient.

During a telephone interview on 09/30/21 at 4:30 PM with RN #5 she said the patient was brought in by the police and EMS due to concerns about her, and they wanted her to be evaluated. Patient #1 was nonverbal. She attempted to leave several times. She would bring notes to the secretary telling her she wanted to leave. She said she had hearing and vision problems. Her notes were perfectly written. When she attempted to leave and staff would talk to her she would have this little smile, almost a smirk on her face. She would remove her monitor and her IV and leave her room. The patient had no problems navigating through the halls of the ED. RN #5 alerted security about the patient being an elopement risk. Before Patient #1 left for the last time she dressed herself completely and left. The police arrested her outside of the building. The police did not talk with RN #5 before they arrested Patient #1.