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Based on review of twenty-one emergency department records, patient #1's record from hospital #2, review of the hospital's bylaws, and review of the policies and procedures for patients who present to the emergency department, it was determined that in one (patient #1) of twenty-one patients who presented to hospital #1 requesting emergency services, the hospital failed to ensure compliance with 489.24. Patient #1's ED record and staff interviews indicated patient#1 presented to hospital with complaints of back pain at 8:18 p.m. on 6/12/16. Patient #1's vital signs were checked at 8:19 p.m., and the patient was triaged at 8:39 p.m. The staff determined that patient #1's behavior, which included lying on the floor and yelling and swearing at staff, was inappropriate and unacceptable. The patient was not provided a medical screening examination prior to security escorting patient #1 from the building at 8:42 p.m.on 6/12/16. This resulted in an immediate jeopardy to the patient's health and safety. The deficient practice is cited at 42 CFR 489.24, C2406.

Based on review of patient #1's ED record, hospital #1 failed to ensure that each patient who presented to the emergency department received a medical screening examination, to determine whether or not an emergency medical condition existed, in one of twenty-one patients reviewed (Patient #1). Findings include:

A sign posted on the wall in ED #1's waiting room described acceptable behavior in the ED. The sign stated patients are expected to treat others with respect and dignity, respect the rights of other patients to have a safe and calm treatment experience, speak and act quietly and refrain from swearing, physical abuse and harassment.

Review of patient #1's ED record and staff interviews revealed that patient #1 arrived at hospital #1's ED on 6/12/16 at 8:18 p.m. The patient complained of back pain. The patient's vital signs were checked at 8:19 p.m., and the patient was triaged at 8:39 p.m. The patient's vital signs were within normal limits, the patient's triage acuity was four, and the patient did not appear to be in pain.

Patient #1's ED record and staff interviews revealed that patient #1 was lying on the floor in the ED and when staff asked patient #1 why she came to the ED, she swore at staff and said her back was painful. Staff asked the patient to get into a wheelchair and wait to be seen. Patient #1 got out of the wheelchair and was found lying on the floor under the triage desk, and she swore and yelled at staff after security staff asked her to be polite and wait to be seen by the physician. The patient continued to yell and swear at staff and refused to cooperate, so security escorted the patient off of the grounds. Review of the record did not indicate that patient #1 was provided a medical screening examination prior to security escorting the patient out of hospital #1.

Patient #1's ED record from hospital #2 was reviewed. The record indicated the patient arrived at ED #2 via ambulance at 11:18 p.m. on 6/12/16. The patient complained of low back pain that started that morning. The record did not indicate that patient #1 was uncooperative or that patient #1 displayed any inappropriate behaviors during the ED visit. The record indicated she was admitted to hospital #2 on 6/12/16 with acute pancreatitis following a medical screening examination that included diagnostic imaging and laboratory tests. The patient was admitted to an observation unit for pain control. The patient was discharged from hospital #2 on 6/15/16.

Nurse (D) was interviewed in person on 6/20/16 at 9:00 a.m. and stated she observed patient #1 lying on the floor under the triage desk during patient #1's visit to the ED #1 on 6/12/16. Patient #1 was very loud, swearing and verbally threatening to staff. The patient refused to get up off of the floor and refused to stop yelling and swearing. The ED was very busy and there were several patients who observed patient #1's behavior while waiting to be seen. Staff and security asked patient #1 to change her behavior, but she refused to act appropriately, and security escorted her out of the hospital.

Nurse (H) stated that while patient #1 was waiting in line to see a physician, she was yelling and swearing at staff. Patient #1 also laid down on the floor twice and refused to get up off of the floor and continued to swear at staff. Nurse (H) brought patient #1 a wheelchair, but she refused to sit in it. Patient #1 did not appear to be in pain when she was lying on the floor. Patient #1 had not been waiting in line for a long period of time. Nurse (H) asked patient #1 to act appropriately and not to swear and yell at staff. The patient refused to change her behavior, so security staff escorted patient #1 out of the hospital.

Patient #1 was interviewed by phone on 6/21/16 and stated she was having pain when she went to ED #1 on 6/12/16. She said she swore at staff, laid on the floor in the ED and did not want to sit in the wheelchair because she was having pain. She said it was very busy in the ED and many patients were waiting to be seen. Patient #1 said staff did not give her a "warning" about swearing and laying on the floor. Security staff walked patient #1 out of the hospital. Patient #1 called an ambulance and was taken to hospital #2 for care.

The hospital's EMTALA policy, dated September 2002 and revised on 10/5/15, states the "hospital shall provide emergency medical services in accordance with the requirements of EMTALA and applicable regulations. The hospital shall not engage in actions that discourage individuals from seeking emergency medical services, and it shall provide medical services without discrimination and regardless of health coverage or financial status. A MSE (medical screening exam) must be performed by Qualified Medical Personnel sufficient to determine if the individual has an EMC (emergency medical condition). The results of this exam shall be documented in the patient medical record."