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Based on record review, interview, and observation the facility staff failed to provide EMTALA (Emergency Medical Treatment and Active Labor Act) signs posted in Spanish specifying the rights of individuals under EMTALA regulations in 4 of 4 areas where EMTALA signs were located: (Emergency Department (ED) waiting area; ED entrance; main hospital entrance; and Obstetrics (OB) waiting area/entrance); and failed to complete a medical screening exam (MSE) on a patient presenting to the Emergency Department (ED) for medical care in 1 of 20 medical records reviewed (Patient (Pt) #1), in a total sample of 20 medical records reviewed; and failed to ensure all staff are trained in EMTALA (Emergency Medical Treatment and Active Labor Act) in 37 of 131 Security officers listed on the Security Meeting Attendance Roster (April 2022 Staff Meeting).

Findings include:

The facility staff failed to provide EMTALA (Emergency Medical Treatment and Active Labor Act) signs posted in Spanish specifying the rights of individuals under EMTALA regulations in areas where EMTALA signs were located: (Emergency Department (ED) waiting area; ED entrance; main hospital entrance; and Obstetrics (OB) waiting area/entrance). See Tag A-2402

The facility staff failed to complete a medical screening exam (MSE) on a patient presenting to the Emergency Department (ED); and failed to ensure all staff are trained in EMTALA (Emergency Medical Treatment and Active Labor Act). See Tag A-2406

Based on observation, record review, and interviews facility staff failed to provide EMTALA (Emergency Medical Treatment and Active Labor Act) signs posted in Spanish specifying the rights of individuals under EMTALA regulations in 4 of 4 areas where EMTALA signs were located: (Emergency Department (ED) waiting area; ED entrance; main hospital entrance; and Obstetrics (OB) waiting area/entrance), in a total sample of 4 areas observed.

Findings Include:

A review of the facility policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) last revised on 07/01/2021 revealed, "... J. Each department that provides emergency services and main entrance areas shall post a sign in English and Spanish in places likely to be noticed by all individuals entering the facility..."

During an observation on 02/21/2023 at 9:50 AM of the main hospital entrance, there were no signs posted in Spanish specifying the rights of individuals under EMTALA regulations.

During an observation on 02/21/2023 at 9:59 AM of the ED entrance, there were no signs posted in Spanish specifying the rights of individuals under EMTALA regulations.

During an observation on 02/21/2023 at 10:00 AM of the main waiting area of the ED, there were no signs posted in Spanish specifying the rights of individuals under EMTALA regulations.

Per observations on 02/21/2023 at 10:20 AM of the EMTALA signs posted on the OB floor and waiting area, the signs were not posted in Spanish specifying the rights of individuals under EMTALA regulation.

An interview with Executive Director of Patient Safety B on 02/21/2023 at 9:53 AM confirmed there were no signs posted in Spanish specifying the rights of individuals under EMTALA regulation in the main admitting area of the hospital.

During an interview on 02/21/2023 at 9:59 AM with ED Manager G when asked what populations the hospital serves, s/he stated, "Spanish speaking is the other most common besides English speaking."

During an interview on 02/21/2023 at 10:10 AM with ED Manager G when asked what languages the ED EMTALA sign postings were posted in s/he stated, "We only have English language signs posted in the main ED waiting area and the ED patient rooms."

During an interview on 02/21/2023 at 10:23 AM with Labor and Deliver (L & D) Nurse Manager F, when asked what languages the OB sign postings were posted in s/he stated, "I don't think we have any Spanish speaking signs. We only have English language signs posted in the OB waiting area and OB patient rooms."

Based on record review and interview the facility failed to complete a medical screening exam (MSE) on a patient presenting to the Emergency Department (ED) for medical care in 1 of 20 medical records reviewed (Patient (Pt) #1), in a total sample of 20 medical records reviewed; and failed to ensure all staff are trained in EMTALA (Emergency Medical Treatment and Active Labor Act) in 37 of 131 Security officers listed on the Security Meeting Attendance Roster (April 2022 Staff Meeting), in a total of sample of 1 month reviewed.

Findings Include:

Review of policy and procedure titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) last reviewed 07/01/2021 revealed the following:
-An appropriate Medical Screening Examination (MSE) will be provided to individuals of any age who present to the Emergency Department (ED) or other hospital property requesting or requiring an examination or treatment for a medical condition to determine if an Emergency Medical Condition (EMC) exists.

Review of policy and procedure titled, "Triage in the Emergency Department" last reviewed 02/01/2022 revealed the following:
-Any patient who presents to the ED requesting examination or treatment for a medical condition must be provided with an appropriate medical screening examination to determine if he/she is suffering from an emergent medical condition.
-If the triage RN (Registered Nurse) is aware that a patient is leaving prior to a medical screening, the RN will encourage the patient to remain for ongoing care and treatment.

Review of Pt #1's ED Care Timeline revealed the following:
1/03/2023:
-8:06 PM-- Pt #1 arrived in the ED with the "Arrival Complaint" of "Assault".
-8:17 PM--RN K ED Triage Note revealed, "Pt in room with mother. Pt yelling at mother 'get out of here!' Pt was jumped today before coming into ED. Pt with abrasion to right abdomen and right knuckle. Pt denies getting head hit and denies LOC (loss of consciousness). Pt is not on blood thinners. Pt pacing in triage room. Pt going into bedside carts and pulling out items. Pt asked to sit on chair. Pt denied and continued to pull items out. Security outside of room. Pt with a flight of ideas. No past medical history on file."
-8:20 PM--Vital signs completed, Triage Assessment completed (Level 3).
-8:20 PM--RN R ED Note revealed, "Writer spoke with visitor (mother) who brought patient to ED. Patient in triage room screaming at visitor and telling her to get out. Writer removed visitor from situation. Visitor states that pt left (behavioral health facility) today AMA (against medical advice), was admitted for 'extreme mania'. Visitor states pt checked out of institution and was jumped by 'people on the street and they threw (Pt #1) off a porch'...Visitor wishes for pt to be re-admitted to (behavioral health facility)..."
-8:22 PM--RN K ED Note revealed, "Pt yelling out in waiting room and pacing."
-8:53 PM--RN K ED Note revealed, "Patient dismissed"; "Pt yelling in waiting room. Security assisted. Security escorted pt out of ED.

Review of an incident report dated 01/03/2023 at 9:24 PM written by Security (officer) L, revealed that an incident involving Pt #1 occurred at 01/03/2023 at 8:48 PM and ended on 01/03/2023 at 9:00 PM. The incident report revealed, "(Pt #1)...in the ED waiting room screaming at staff, completely disruptive and not listening to MCSO (Milwaukee County Sheriff Officer). (Pt #1) was wheeled to the Back Triage Entry. MCSO deputies spoke to her for a few minutes and then (Pt #1) headed back to the Lobby Seating Area. While in the Waiting Area, (Pt #1) continued to be disruptive. MCSO made contact with (Pt #1) and brought (Pt #1) back to the Back Triage Area. At this time, (Pt #1) was becoming more verbal and then attempted to spit in a deputy's (MCSO Q's) face. MCSO and FMLH (hospital security) officers went hands, attempting to detain the patient. Once (Pt #1) was cuffed, (Pt #1) continued to resist as she/he was carried to a squad car. (Pt #1) was placed under arrest and conveyed off campus by MCSO."

Review of facility Safety Event SI-944411 Meeting Minutes dated 01/12/2023 from 1:00 PM to 2:00 PM, in response to the incident regarding Pt #1, revealed the following:
1. Question: "Was there opportunity to engage a provider to assist with assessing and managing (Pt #1's) behaviors?"; Answer: "Always an opportunity to engage EM (Emergency Medical) provider, SW (social worker), ED Psych (Psychiatrist/Psychologist)."
2. Question: "Was this engaged?"; Answer: "Per (RN K) no consults were made on (Pt #1's) behalf."
3. Question: "Was there an opportunity to engage with law enforcement prior to them taking (Pt #1) out of the ED?"; Answer: "Security did not discuss with staff per (RN K) report, prior to (Pt #1's) removal from waiting room."
4. Question: "Did Security assist law enforcement with removing the (Pt #1) from the ED..."; Answer: "Per (RN K) (Pt #1) was placed back in waiting room with mother after triage complete...Pt then seen settling down in wheelchair in front of triage by (RN K). A little while later (RN K) state patient was no longer in wheelchair, (RN K) heard a commotion near the vending machines but could not visualize the situation. Next thing (RN K) saw was security and sheriff carrying (Pt #1) out of department. (Security/law enforcement) did not check in with triage desk or speak with any staff members prior to removing (Pt #1)."
5. Question: "Is there enough documentation in the chart that clarifies the event that occurred or is there an opportunity to provide more insight and clarity in the future?"; Answer: "No call x 3 completed. (Pt #1) seen being removed from the ED by security so (RN K) dismissed patient from waiting room."
6. Question: "Any immediate mitigation decisions made?"; Answer: "Leadership team in agreement no immediate action needed at this time. Continue collaboration with security leadership."
7. "Contributing Factors" include but are not limited too,: "No provider care involved in case", "(Pt #1) taken prior to medical screening", "(Pt #1) disruptive to other patient in waiting area", "Security and LEO (Law Enforcement Officer) acted independently without clinical team or communication."

Review of the Security Meeting Attendance Roster for April 21, 2022 (which included annual training for EMTALA), revealed that 37 of the 131 Security officers on the roster, were not signed off as attending the EMTALA training.

Per interview with Patient Services Specialist C on 02/22/2023 beginning at 8:45 AM, Patient Services C stated that Security staff received EMTALA training during their staff meeting on 04/21/2022. Patient Services C confirmed the findings, and stated that there was no documented evidence of the 37 Security Officers receiving annual/initial EMTALA education. Patient Services C stated that all Security staff should receive EMTALA education on hire and annually thereafter.

During interview with Milwaukee County Sheriff's Officer (MCSO) Q on 02/21/2023 at 4:01 PM, MCSO Q revealed that he/she remembered Pt #1 coming into the ED acting "belligerent", "obnoxious", "loud", and "non-compliant with nursing staff." MCSO Q stated that Pt #1 arrived in the ED to seek medical treatment after being assaulted and "jumped by 3-4 individuals." MCSO Q stated that Pt #1 was laughing and screaming at the other Security Officers in the waiting area. MCSO Q stated that he/she "Wanted (Pt #1) to be seen and medically evaluated", but Pt #1 had to "calm down." MCSO Q stated, "If someone is actively fighting officers and is a threat to other patients in the waiting room, I cannot put other patients at risk. So I placed (Pt #1) in hand cuffs and escorted (Pt #1) to the squad car." MCSO Q stated that he/she did "not recall" if nursing staff was aware of MCSO Q detaining Pt #1 and taking her/him to another medical facility. MCSO Q stated that he/she did not "recall" receiving EMTALA training.

During an interview with Security Officer (Supervisor) O on 02/21/2023 at 4:40 PM, when asked about Pt #1 and what Security O witnessed in the ED, Security O stated, "I saw that MCSO Q had (Pt #1) in the squad car. I did not know they were going to take (Pt #1) to another facility without a medical screening exam. I mentioned to MCSO Q that (Pt #1) needed a medical screening, and MCSO Q stated that she/he asked (Pt #1) 3-4 times if (Pt #1) wanted treatment, and (Pt #1) denied wanting treatment." Security O stated that nothing was signed before (Pt #1) was escorted off the property. When asked what the expectation is for Security Officers and communication with the clinical staff, Security O stated, "I would expect security staff to communicate with ED nursing staff." Per interview Security O stated that he/she would never expect a patient to be "forced" off the property, and that Security O was not told that MCSO Q was taking Pt #1 to another medical facility.

During an interview with Security (Sergeant) N on 02/21/2023 at 4:20 PM, when asked about Pt #1 and what Security N witnessed in the ED, Security N stated that he/she heard Pt #1 screaming, yelling, making threats to people and officers in the ED, and witnessed MCSO Q talking to Pt #1 asking her/him to calm down. Security N stated that he/she witnessed Pt #1 kick and spit on MCSO Q; Security N stated MCSO Q took Pt #1 to the ground, hand cuffed Pt #1, then proceeded to take Pt #1 outside and into the squad car...Security N stated that his/her impression was that Pt #1 was going to be medically screened at the facility and then sent to another facility. Security N stated that he/she thought that Pt #1 was going to "sit in the squad car" until Pt #1 was called back into the ED for an exam. Security N stated that "no nurses ever came out" during or after this incident.

During an interview with RN K on 02/21/2023 at 5:20 PM, RN K confirmed that she/he triaged Pt #1. RN K stated that after triage, RN K directed Pt #1 to the waiting room because there were no open rooms; Pt #1 was heard yelling at her/his mom and people in the waiting room. RN K stated that while triaging another Pt, RN K heard yelling and observed MCSO Q carrying Pt #1 out of the ED main entrance. RN K stated that security officers and MCSO Q did not speak to RN K about the incident that occurred and did not ask if Pt #1 received a medical screening exam. When asked if RN K communicated with Security Officer or the Sheriff's Deputy after witnessing Pt #1's removal from the ED, RN K responded "No, I did not follow up." Per RN K she/he just "assumed" Pt #1 was with her mother.

During interview with Assistant ED Manager E on 02/21/2023 at 12:50 PM, Manager E stated that Pt #1 was removed from the ED by Security Officers and the Sheriff's Deputy without notifying nursing staff. Manager E stated that Security Officers and Sheriff's Deputy should collaborate with nursing staff before removing a patient from the facility and taking a patient to a different medical facility and "this did not happen." Manager E stated that Pt #1 did not receive a medical screening exam before Pt #1 was taken off the property to another medical facility.

Per interview with Assistant ED Manager E and Clinical Nurse Specialist (CNS) J on 02/22/2023 beginning at 10:00 AM, when asked whose responsibility it is to ensure patients receive a medical screening exam, ED Manager E stated, that it is a "collaboration" between the triage RN and the covering physician. CNS J stated that she/he would expect the clinical team (RN, Physician) to discuss the risks and options with those patients that inform staff that they no longer want to be seen by a provider. CNS J and ED Manager E both agreed that they would not expect Security Officers and/or the Sheriff's Deputy to have those conversations with the patient. ED Manager E stated that the Security Officers are the "medical liaison" between the Sheriff's Deputy and the clinical staff.

Per interview with Director of Patient Safety B on 02/22/2023 at 11:45 AM, Director B stated that the Milwaukee County Sheriff's Department is contracted with the hospital to station law enforcement officers in the hospital/ED; and law enforcement officers work in conjunction with Security Officers directly employed by the hospital.