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Based on review medical records (MR), Central Log review, Emergency Medical Service (EMS) report review, policies and procedures review, and interviews it was determined the facility failed to ensure that one of 21 sampled patients (P) (P#15) was informed of the risk and benefits of a medical screening examination (MSE) and/or treatment when P#15 arrived via Emergency Medical Services (EMS) to the Emergency Department (ED) on 7/21/21, and informed ED staff that she was leaving prior to receiving a MSE. Additionally, the facility failed to ensure that P#15's medical record (MR) contained a description of P#15's refusal to receive an MSE.

Findings were:

Cross refer A-2407, as it relates to the facility's failure to provide P#15 with the risk and benefits of a receiving a medical screening.

Based on review medical records (MR), Central Log review, Emergency Medical Service (EMS) report review, policies and procedures review, and interviews it was determined the facility failed to ensure that one of 21 sampled patients (P) (P#15) was informed of the risk and benefits of a medical screening examination (MSE) and/or treatment when P#15 arrived via Emergency Medical Services (EMS) to the Emergency Department (ED) on 7/21/21, and informed ED staff that she was leaving prior to receiving a MSE. Additionally, the facility failed to ensure that P#15's medical record (MR) contained a description of P#15's refusal to receive an MSE.

A review of the EMS Care Report Narrative from 7/21/21 revealed the ambulance arrived at 2:45 p.m., P#15 complained of a burning sensation in her chest since that morning. P#15 was transported non-emergently to the facility's Emergency Department (ED). P#15 was being monitored by EMS with an electrocardiogram (EKG) (test to detect abnormal heart rhythm) at 2:52 p.m. P#15 was notified by EMS that the ED was on diversion (not accepting patients), and the patient chose to go to the facility's ED. The ambulance arrived to the ED at 3:24 p.m. Non-cardiac chest pain was listed as the patient's chief concern.

A review of the ED record revealed that P#15 arrived at the ED and was in the ED lobby at 3:29 p.m. P#15 complained of chest pain. An EKG that EMS completed was unremarkable (normal).

A review of P#15's discharge notes revealed that P#15's family was upset due to the wait time and wanted to take P#15 to the primary physician or a different hospital. Registered Nurse (RN) LL documented that P #15 was dismissed from the ED at 3:45 p.m. The entry did not specify if the patient left without treatment or left without being seen. A review of the facility's ED Central Log revealed that Patient (P) #15 presented to the ED on 7/21/21 and left without treatment.

A review of the medical record, the facility failed to document if P#15 received information that outlined the risk and benefits of the patient leaving the hospital prior to receiving an MSE and/ or treatment or both from a provider.


During a telephone interview with the complainant on 8/3/21 at 10:30 a.m., the complainant stated he arrived at the ED at the time that P#15 had been rushed to the ED by ambulance and taken into the back part of the ED. The complainant said P#15 came out of the ED less than 10 minutes after arrival and was asked to sit on a bench outside the ED until a room became available. P#15 still had an IV in her arm and EKG stickers placed on her by the ambulance. The complainant asked P#15 if her vitals were checked or if she was given anything for a headache. The complainant stated that P#15 told him nothing was done except to obtain her billing information. The complainant said he waited in line to ask the person at the front desk why nothing else was done for P#15. The person at the desk said to discuss the issue with the nurses. The complainant stated there were three nurses near the front desk, so the complainant told the nurses that P#15 was rushed there by ambulance with a headache, elevated blood pressure, and chest pain, and there was no check on her. The nurses said there was not a room available, and P#15 had already been checked by the ambulance. The complainant was concerned that P#15's condition would worsen. The complaint was told it would be a long time before the ED could see P#15, so the complainant told the ED to discharge her. The IV was left in the patient's arm and removed at a different hospital.

During an interview with the ED Nurse Director (RN) CC on 8/2/21 at 11:52 a.m. in the conference room, RN CC stated patients with an acuity (acuity is the severity of an illness or injury) of 1 or 2 (1 is the most severe) would be brought back without a wait. Examples of high acuity would be gunshots or cardiac arrest. Low acuity patients would be brought back to be registered. The patient would be asked about demographics and the chief complaint. If a patient were low acuity and the ED was completely full, the patient would be taken by wheelchair to the front triage area. Sometimes, there would be a brief wait for triage. The triage nurse would have protocol orders for blood tests, EKG, and x-ray that the triage nurse would initiate. For example, when a patient complained of chest pain or cardiovascular, the goal would be to have an EKG within 10 minutes. RN CC said the ED had an external waiting area to help with volume and social distancing just outside the ED.

During an interview with Registrar DD on 8/2/21 at 12:50 p.m. in the ED, Registrar DD was asked about the registration process. Registrar DD said when a patient came through the ED door and arrived at the window, the registrar would first put the patient in the computer system. Then, the patient would be asked to take a seat in the waiting area and instructed that a nurse would call the patient's name to start triage. Registrar DD said if the patient were in a critical condition, such as a gunshot or a heart attack, the registrar would call the nurse to receive the patient. Registrar DD said the patient would not go back to the waiting area, but a nurse would come and start the triage process.

During an interview with the triage nurse (RN) EE on 8/2/21 at 1:00 p.m. in the triage room, RN EE said she had a computer screen to see who was put in the system after the patient had been registered. RN EE said patients would be triaged by acuity or level of severity. RN EE said if a patient came to the ED acutely ill, there would be an ED physician in a room right across from her that she would call. The provider would perform a medical screening before or during triage. After the initial screening, RN EE said she would monitor the patient at least every two hours and check vital signs. RN EE said the triage time would be about 20 minutes. The hospitalist, Nurse Practitioner (NP), or Physician Assistant (PA) would be the qualified providers to perform a medical screening.

An interview was conducted with ED Charge Nurse (RN) HH on 8/2/21 at 1:15 p.m. at the ED nurse's station. RN HH stated the ED would try to have patients triaged as soon as the patients arrived at the ED. The time it took for triage or to see a provider depended on how sick the patients were when arriving at the ED.


An interview was conducted with the ED Nurse Manager (RN) MM on 8/4/21 at 10:56 a.m. in the conference room. RN MM stated the charge nurse would have a report from the paramedic and would make the determination whether the patient went to the waiting room prior to triage. Triage times would depend on volume, and the goal would be to triage 5-10 minutes after arrival.

During a telephone interview with P#15 on 9/27/21 at 10:53 a.m., P#15 stated Emergency Medical Services (EMS) brought her to the Emergency Department (ED) with an IV in her arm and waited with P#15 against the wall of the ED. The patient's identification and other information were provided to the ED by EMS. P#15 stated she asked to use the restroom while the nurse spoke to EMS. P#15 stated after she left the restroom, the nurse said, "I ' m so sorry", then opened the doors to the waiting area. P#15 said the waiting room "looked like the Apocalypse" because so many people were waiting in the area. P#15 stated Security directed P#15 to wait outside the ED on the benches where people smoked because that was where seating was available. P#15 said she was not aware of the exterior waiting rooms on each side of the ED. P#15 stated she was light-headed, her blood pressure was through the roof, and no one told her what was happening or gave her any information. P#15 stated she left the ED with the IV still in her arm and went to a different hospital.


The facility's Policy titled "Transfer Activities in Accordance with EMTALA Requirements Policy," Policy ID :815291, revised 6/4/20 was reviewed. The Policy revealed in part, " ...4.
Policy ... Obtaining or attempting to obtain written informed refusal of examination, treatment ...when if a patient refuses such action." The facility failed to ensure that their policy and procedure was followed as evidenced by failing to take all reasonable steps to secure Patient #15's written informed refusal of an examination and/or treatment.