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Based on review of the facility's Medical Staff Rules and Regulations, review of facility policies, observations of a digital security video recording, review of medical records, and interviews the facility failed to provide a Medical Screening Examination (MSE) for one (P#2) patient of 33 patients reviewed. These failures resulted in Patient #2 leaving Hospital A's Emergency Department (ED) after waiting 3 hours 23 minutes without an MSE being completed. Immediately after leaving the ED at Hospital A the patient was taken by family members to Hospital B where he was provided an MSE and his Emergency Medical Condition was treated.

The findings included:

Refer to A-2406.

Based on review of the facility's Medical Staff Rules and Regulations, review of facility policies, observations of a digital security video recording, review of medical records, emergency department log, and interviews the facility failed to provide a complete Medical Screening Examination (MSE) for one (P#2) patient of 33 patients reviewed. This failure resulted in Patient #2 leaving Hospital A's Emergency Department (ED) after waiting 3 hours 23 minutes without an MSE being completed. The patient was immediately transported by family members to Hospital B where he was provided an MSE and his Emergency Medical Condition was treated.

The findings included:

Review of Medical Staff Rules and Regulations last revised July 2021, revealed, "...The screening of individuals seeking emergency medical care in the Emergency Department, for the purpose of determining whether the individual has an emergency medical condition [EMC] that requires stabilizing treatment, shall be done by the Emergency Department Physician, or by an appropriately credentialed Physician Assistant and/or Nurse Practitioner..."

Review of facility policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Guidelines" dated January 2014 revealed, "...A Medical Screening Examinations (MSE) will be performed for any individual that...presents on hospital property and requests examination or requires treatment for what may be an emergency medical condition..."

Observations of a digital security video recording dated 4/17/22 revealed Patient #2 entered the ED with his mother on 4/17/22 at 7:38 PM. Continued observations revealed he and his mother immediately presented to the registration desk at 7:39 PM where he and his mother interacted with staff at the desk and then both went to a corner of the waiting room. Continued observations of the video revealed the patient and his mother went to the registration desk and talked to ED Technician #1 at 10:17 PM. Continued observation revealed the patient's blood pressure being taken by ED staff at 10:18 PM. Continued observation revealed Patient #2 and his mother leaving the ED on 4/17/22 at 11:01 PM.

Review of the Emergency Department Log at Hospital A revealed Patient #2 presented to the ED on 4/17/22 at 7:46 PM. Review of Patient #2's ED medical record from Hospital A revealed the patient was triaged on 4/17/22 at 7:55 PM. Continued review revealed "...pt [patient] states supra pubic catheter [a tube inserted through the outside of the abdomen into the bladder] is not draining, he has tried to flush it and move it around with no relief. States he is having spams [spasms]..." Continued review revealed the patient's vital signs at triage (7:55 PM) were:
Blood Pressure = 121/71 (normal less than 120/80)
Oxygen Saturation = 95% (normal 95-100%)
Respiration = 19 (normal 12-20)
Pulse = 89 (normal 60-100)
Temperature = 37.2 degrees (98.9 F/normal 97.0 to 99.0)

Review of an ED Note Physician written by Physician's Assistant #1, dated 4/17/22 at 8:37 PM, revealed, "...Patient was briefly seen in Triage in conjunction with RN [Registered Nurse] to perform medical screening exam and expedite orders. Patient will be fully examined, treated, and dispositioned by another ED provider in the Emergency Department. Elements included History, ROS [Review of Systems], and Physical Exam will be completed in detail at a later time. My examination provides and initiation of medical screening exam and preliminary orders will be placed to facilitate care of the patient...Patient advised of the risk of leaving prior to completion of care...history of quadriplegia [paralysis in all four limbs] presents to the emergency department for evaluation of his suprapubic catheter. States it was changed approximately 2 weeks ago. He states it became clogged today secondary to sediment...States he has developed dysreflexia [Dysreflexia also called Autonomic Dysreflexia is a serious life-threatening condition found in patients with spinal cord injuries] and chills which he states occurs when his catheter becomes clogged. Patient notes he was uroseptic [infection of urinary tract] two weeks ago...Brief Physical Exam...well appearing in no acute distress...Clinical impression: Suprapubic catheter complications..."

Continued review revealed a second set of vital signs with no time documented, but observed on video recording as being done at 10:18 PM on 4/17/22, were:
Blood Pressure = 174/116
Pulse = 62
Respirations = 19
Oxygen Saturation = 100%
Temperature = 37.2 (98.9 F)

Continued review revealed "...ED Checkout Date and Time: 04/18/22 03:07:11...Diagnosis...Left without Treatment Completion..." Continued review revealed no documentation of the patient's MSE being completed. Continued review revealed no documentation of staff informing the patient of the benefits of remaining in the ED for assessment and treatment. Continued review revealed no documentation of staff informing the patient regarding the risks of leaving the ED prior to the MSE being completed. Continued review revealed no documentation of the patient leaving Against Medical Advice (AMA).

Review of the Medical Record from Hospital B revealed Patient #2 presented to the ED at Hospital B on 4/17/22 at 11:19 PM. Continued review revealed the patient was provided a MSE by a Medical Doctor on 4/17/22 at 11:44 PM. Continued review of the ED Physician's Note dated 4/17/22 at 11:44 PM revealed, "...The patient presents for a catheter check. The onset was Suprapubic catheter is not draining all day. Patient c/o [complaining of] bladder spasms...Using sterile technique suprapubic catheter was replaced and is now draining well..." Continued review revealed the patient was discharged home from Hospital B in stable condition on 4/18/22 at 1:55 AM.

Interview with Patient #2's mother was completed by telephone on 5/11/22 at 12:05 PM. The mother confirmed she took the Patient #2 to the ED at around 7:30 PM on 4/17/22. Continued interview revealed the patient was in a powered wheelchair and she accompanied him into the ED and stayed with him through his entire visit there. Continued interview revealed the patient had paralysis in all four limbs due to a previous cervical injury and his supra-pubic catheter was not draining properly. Continued interview revealed because the patient's bladder was not being drained by the catheter his blood pressure was elevating secondary to the patient having "...dysreflexia..." (Also called Autonomic Dysreflexia is a serious life-threatening condition found in patients with spinal cord injuries). Continued interview revealed the mother had communicated to the ED staff her concern regarding the patient's dysreflexia and the danger of the patient's blood pressure continuing to elevate. Continued interview revealed the patient was triaged by a nurse and examined by a Physician's Assistant and told to wait in the waiting room. Continued interview stated the patient's blood pressure was increasing and the patient had urine leaking around the catheter and onto his clothes and onto the ED floor. Continued interview revealed the mother repeatedly communicated to the nurse at the desk (ED Technician #1) her concern about the patient's worsening condition, but staff did not do anything for the patient. Continued interview revealed that after 3 hours waiting the mother took the patient up to the nurses desk and again expressed her concern of the patient's blood pressure elevating. Continued interview revealed the ED staff at the desk took the patient's blood pressure and it was very elevated (does not remember what it was). Continued interview revealed they waited approximately 10 more minutes, and then told the nurse working at the desk to take the IV (intravenous needle/catheter used to administer IV fluids) out as they were leaving to get the patient some help. Continued interview revealed the nurse removed the IV and the mother and patient left the ED. Continued interview revealed none of the ED staff advised the patient or mother to remain in the ED prior to them leaving Hospital A. Continued interview revealed none of the ED staff advised her or the patient of the risks of leaving the ED at Hospital A. Continued interview revealed the mother drove the patient immediately to Hospital B where they were quickly examined and treated. Continued interview revealed the patient's catheter was changed at Hospital B and his blood pressure quickly dropped.

Telephone Interview with Physician's Assistant (PA) #1 was completed on 5/10/22 at 10:10 AM. PA #1 stated she remembered Patient #2's ED visit on 4/17/22. Continued interview revealed PA #1 did an examination and obtained a brief history from the Patient #2 when he was triaged. Continued interview revealed the patient only wanted his supra pubic catheter changed, but PA #1 stated she felt he needed some diagnostic laboratory tests done to rule out infection or other complications. Continued interview revealed there were no treatment rooms available in which to change the patient's catheter and he had to wait in the waiting room until a treatment room was available. PA #1 stated changing the catheter was not something they could do in a hallway or wheelchair and all the treatment rooms and stretchers were occupied at that time. Continued interview revealed the patient did not appear in any acute distress and appeared in stable condition when PA #1 examined him. Continued interview revealed PA #1 had advised the patient on the risks of leaving prior to completion of his care. Continued interview revealed PA #1 did not see or speak with Patient #2 again after the initial examination. Continued interview revealed the patient left the ED prior to the MSE being completed.

Interview with the ED Director in the ED Director's office on 5/10/22 at 10:40 AM revealed Patient #2 had left the ED on 4/17/22 prior to his MSE and treatment being completed. Continued interview revealed there was no documentation in the medical record of staff notifying the patient regarding the risks of leaving the ED prior to the MSE being completed. Continued interview revealed there was no documentation in the medical record of the patient leaving AMA and there was no AMA form signed.

Telephone interview with ED Technician #1 was completed on 5/11/22 at 6:16 AM. ED Technician #1 stated she remembered Patient #2's visit to the ED at Hospital A on 4/17/22. Continued interview revealed she remembered the ED was very busy that night, and all treatment rooms were occupied. Continued interview revealed Patient #2's mother spoke with ED Technician #1 "...several times..." while waiting for a treatment room to become available. Continued interview revealed the patient and his mother came to the desk concerned regarding the patient's blood pressure. Continued interview revealed ED Technician #1 took the patient's vital signs again and reported the patient's elevated blood pressure to one of the ED nurses. Continued interview revealed the mother and patient decided to leave the ED and seek care somewhere else. Continued interview revealed the patient requested his IV be removed so he could leave, and ED Technician #1 removed the patient's IV as requested. Continued interview revealed the patient immediately left the ED after the IV was discontinued. Continued interview revealed the ED Technician was the only hospital employee that talked to the patient and his mother before they left the ED on 4/17/22. Continued interview revealed the ED Technician did not tell the patient and/or mother about the benefits of waiting at the ED for the MSE and treatment to be completed. Continued interview revealed the ED Technician did not tell the patient and mother about the possible risks of leaving the ED before the MSE and treatment were completed. Continued interview revealed the patient was not asked to sign an AMA form before leaving the ED.