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Based on staff interview, medical record review of nursing note and encounter summary, video surveillance review, and facility policy and procedure review, the facility failed to follow its policy and procedure to obtain a written refusal of a medical screening exam (MSE) or document the reason it could not be obtained for one (1) of 20 patients reviewed. Patient #1

Findings Include:

Cross Refer to A2406 for the facility's failure to provide an appropriate medical screening exam (MSE) or obtain written refusal/documentation of why written refusal could not be obtained for Patient #1.

During exit conference on 11/30/2022 at 4:45 p.m. with Chief Executive Officer (CEO), Chief Nursing Officer, and Risk Management Director survey findings were discussed. No further documentation was submitted for review.

Based on staff interview, medical record review of nursing note and encounter summary, video surveillance review, and facility policy and procedure review, the facility failed to follow its policy and procedure to obtain a written refusal of a medical screening exam (MSE) or document the reason it could not be obtained for one (1) of 20 patients reviewed. Patient #1

Findings Include:

Observation of video surveillance on 11/30/2022 at 10:15 a.m. revealed on 11/10/2022 at 6:03 a.m. Registered Nurse (RN) #1 entered exam room with Patient #1 and parents and exited at 6:06 a.m. without a mask. Physician #2 walked to the door with a mask on and spoke with Patient #1's parents from the door and left at 6:07 a.m. Physician #1 enters Patient #1's exam room at 6:09:23 a.m. not wearing a mask and exits the exam room at 6:09:35 a.m. At 6:10 a.m. Patient #1's father exits exam room and speaks to someone out of video view and returns to exam room. At 6:11 a.m. the parents leave the exam room with Patient #1.

A phone interview with Physician #1 on 11/30/2023 at 2:05 p.m. confirms Patient #1 was brought to the Emergency Department (ED) on 11/10/2022 with a fever. Physician #1 said he entered Patient #1's exam room and went to the sink to wash his hands and the father asked him to wear a mask. He stated, "We're no longer required to wear mask anymore ..." Physician #1 stated the father started yelling and cursing at him, so he exited the exam room.

An interview with RN #1 on 11/30/2022 at 2:23 p.m. confirms the father came out of Patient #1's exam room after Physician #1 left the room and asked for Physician #2 and was told Physician #2 had left the ED. RN #1 said the father returned to the exam room and then left the ED with Patient #1 and the mother.

Review of the ED medical record "Nursing Note," dated 11/10/2022 revealed Patient #1 arrived at the ED with parents at 5:59 a.m. and triage was completed at 6:11 a.m. "Presenting complaint: child started running fever this morning ... Acuity: Urgent (3) ...PMHx: sickle cell-hemoglobin SS disease ..." Vital signs: Pulse 170, Temperature 100.2, Pulse Oxygen saturation 100%, weight 8.2 kilograms, pain 0/10.

Review of ED medical record "Encounter Summary" dated 11/10/2022 revealed Patient #1 acuity assigned as " ...Chief Complaint: Fever ...and Urgent (3), ...and Outcome: Eloped." The Encounter Summary reveals no documentation for diagnosis, prescriptions, follow up, attending physician, orders, discharge instructions, written refusal of a MSE or the reason a written refusal could not be obtained.

Review of facility's "Emergency Medical Treatment and Labor Act," (EMTALA) Policy ID #9388572 last review date 06/20/2021 revealed " ...Procedure: 7. Refusal of Examination ...If written refusal cannot be obtained, personnel will document the steps taken to secure written refusal and the reason it could not be obtained ..."

During exit conference on 11/30/2022 at 4:45 p.m. with Chief Executive Officer (CEO), Chief Nursing Officer, and Risk Management Director survey findings were discussed. No further documentation was submitted for review.