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Based on interviews and review of records, the facility failed to provide a medical screening (MSE) by a qualified medical provider to determine an emergency medical condition (EMC) exist for 1 of 20 patients reviewed (patient #1) that presented to the Emergency department (ED) on January 26, 2022. Specifically, Patient #1 did not receive an appropriate and thorough MSE to include the necessary assessment and diagnostics that may have detected a potential EMC.


Findings were:

Review of the Complaint Intake TX00409199 indicated the following allegations on behalf of Patient #1.
Patient #1 is a 30 y/o male with a history of back pain. The allegations state that the facility failed to provide adequate care and a complete thorough assessment on 1/26/2022. Further review indicated Patient #1 was taken to the Emergency Department by his family on 1/26/2022 at 11:10 am due to severe back pain / left hip pain and being unable to stand or sit for long periods of time. Patient #1 and his family notified staff that he could not sit due to pain. The patient was greeted and quick registered by a staff member. Patient #1 and family were told that they could not provide a stretcher for him. Patient #1 laid down on the lobby floor. Patient #1 was asked to stand up or sit on a chair due to patient safety by a staff member. Patient #1 and family reiterated that he could not sit nor stand due to the pain. Patient #1 and family member stated that they were told that if he did not sit on a chair or stand up, he could leave. Patient #1 and family decided to depart the ED. Pt #1 stated that the staff member did not offer a triage, discharge paperwork, an explanation nor a list of risks for leaving as he departed. Patient #1 stated that the staff member did not do anything to assist him or offer care. Patient #1 stated that a security guard assisted him to a wheelchair and out of the department. Patient #1 went to another ED where a stretcher was provided, he was treated, stabilized, and discharged.

Review of patient #1's ED record dated 1/26/2022 at 11:10 AM revealed patient arrived at the ED and was preregister (reception) at 11:10 AM. The record shows that the patient's priority and/or acuity was not documented, Vital signs were not documented, and his mode of arrival was not documented. The record shows that the "stated complaint" was documented as "HIP PAIN LEFT". At 11:44 AM The record then shows the patient's disposition as against medical advice (AMA). Disposition documentation that the patient "refused treatment". The record also shows that "Information provided", as refused. The departure portion of the record shows, Disposition as "Routine self-care. condition stable". The record review revealed that no documentation was included for referrals, patient instructions, additional instructions nor departure forms. No AMA form was found in the patient record.

Interview of staff #1, assigned to the greeting station and where the "Reception" took place, on 4/27/2022 at 10:00 AM revealed that stretchers are available for patients that cannot use wheelchairs, sit down or otherwise stand. Staff #1 stated "we have stretchers parked in the back for patients that need them". Staff #1 also stated that if stretchers were not available due to volume or saturation that they would use their resources to alert management.
Interview of staff #3, charge nurse, on 4/27/2022 at 10:30 AM revealed that stretchers are available for patients. The staff member stated that if a patient needs a stretcher "we have them available in the department". Staff #3 also elaborated that if stretchers were not available that they would escalate to management and /or the house supervisor to troubleshoot. Staff #3 stated that "we would assist the patient".

Interview of staff #4 on 5/2/2022 @ 10:00 AM. Staff #4 was on duty the day of the incident and had the final interaction with Patient #1 and family. Staff #4 stated that she observed the patient was on the floor and approached the patient to informed him that his actions constitute a patient safety issue. Staff #4 stated that the patient and family requested a stretcher because he could not sit in a chair. Staff #4 stated that they were full, and stretchers were not available in the department and could not provide a stretcher. Staff #4 denied refusing treatment to the patient but stated that a family member stated that "so, if he does not sit on a chair he will not be seen?". Staff #4 stated that "it was their decision" to leave. Staff #4 stated that the patient and family members declined information regarding the leaving AMA. Staff #4 denied escalating the issue to the MSE provider, charge nurse or house supervisor. Staff #4 denied completing an incident report about the incident.

Review of this facility's Policy #5257662, titled, Texas EMTALA - Medical Screening Examination and Stabilization Policy, last revised on 5/2017. The policy reads as follow; An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED") and: 1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or 2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition.

Review of this facility's policy #10277525, titled, Leaving Against Medical Advice, last revised 9/2021. Reads as follow; Policy, B. If a competent adult patient or patient's legally authorized representative expresses to the staff a desire to refuse admission or leave AMA, the attending physician and Nurse administrator will be notified immediately. All attempts to address the patient's concerns will be made. Procedure; 3. If a patient refuses to sign the release, a notation to this effect should be made on the form (witness by one employee) and in the medical record with a detailed time, date, last seen information, and condition of the patient. The patient can not be forced to sign the release or be prevented from leaving. Tell the patient that they can return at any time. Procedure; 3. If a patient refuses to sign the release, a notation to this effect should be made on the form (witness by one employee) and in the medical record with a detailed time, date, last seen information, and condition of the patient. 4. The nurse will document pertinent information, including but not limited to risk of discharge as explained to the patient, instructions regarding alternative follow up care, relatives and friends in attendance and teaching received, and stated destination. Every effort should be made to contact the attending and, if available, consulting physician so they can discuss the issue with the patient prior to leaving. 6. An occurrence report should be completed.