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The Hospital failed to ensure compliance with EMTALA regulations as one Patient (1) out of a total sample of 30 patients, received a medical screening evaluation (MSE) to determine whether an emergency medical condition existed. Patient #1 presented to the Hospital Emergency Department (ED) with a complaint of a nose fracture and headache and was told to leave by Hospital staff before a provider could perform a MSE on Patient #1 (see tag A2406).

Based on record review and interviews, the Hospital failed to ensure one Patient (1) out of a total sample of 30 patients, received a medical screening evaluation (MSE) to determine whether an emergency medical condition existed. Patient #1 presented to the Hospital Emergency Department (ED) with a complaint of a nose fracture and headache and was told to leave by Hospital staff before a provider could perform a MSE on Patient #1.

Findings include:

Review of the Hospital policy titled "Examination, Treatment, and Transfer of Patients to other Facilities (EMTALA)", dated 6/2022, indicated the following:
-All persons presenting to the Hospital's Emergency Department, the birthplace, or any Hospital campus property seeking care for an Emergency Medical Condition (EMC) shall receive an appropriate MSE. The MSE will be done in accordance with the capabilities of the receiving or nearest department, by a qualified medical person to determine if the patient has an EMC or is in active labor.

Review of the Hospital policy titled "Emergency Department", dated 8/5/2020, indicated the following:
-All patients are assigned a primary nurse. The goal is to provide clinically excellent, safe, quality care and to enhance the patient experience. The Registered Nurse (RN) performs the initial assessment and formulates the plan of care for each patient.
-All patients arriving in the ED will be seen by an ED provider.
-The nurse is responsible for the initial patient assessment and ongoing reassessment according to each patient's clinical condition.

Review of Patient #1's medical record indicated the Patient arrived at the Hospital's ED on 4/25/25 at 3:35 P.M. with complaints of a nose fracture and headache. During nursing ED triage, Patient #1 said he/she had been hit in the nose with some metal and thought it was broken and had a bad headache. Patient #1 was triaged at an acuity level of 3. Patient #1 was moved into an ED overflow room at 5:00 P.M. on 4/25/25 and RN #2 was assigned as his/her nurse. On 4/25/25 at 7:17 P.M., Physician Assistant (PA) 1 was assigned to Patient #1. On 4/25/25 at 7:40 P.M., RN #2 documented Patient #1 was upset he/she had not been seen, was on his/her phone using profanity, and became verbally aggressive with RN #2 when she asked the Patient to stop; RN #2 called security and security asked the Patient to leave and took him/her out to the waiting room. PA#1 documented on 4/25/25 at 8:03 P.M. that Patient #1 left the ED prior to an exam or being seen by a provider. Further review of Patient #1's medical record failed to indicate an MSE was conducted for the Patient, any orders for treatment, nor any pain assessment despite a complaint of nose fracture and headache.

During an interview with the ED Nursing Director on 4/29/25 at 11:10 A.M., he said anyone who presents to the Hospital ED seeking a medical exam should receive one, unless a patient chooses to leave without being seen. He said For verbally or physically belligerent or aggressive patients, the goal should be to first de-escalate the patient. He said If that doesn't work, the nursing staff need to escalate up the provider chain-of-command to ensure the patient is seen by a provider. He said in some cases a restraint may be needed in order to safely evaluate a patient. He said patients should be assessed and a medical evaluation before being discharged. He said all ED staff are trained in de-escalation techniques.

During an interview with RN #2 on 4/29/25 at 11:24 A.M., she said she was assigned to Patient #1 in the ED overflow area. She said Patient #1 had said he/she was assaulted and thought he/she had a broken nose. She said she let the Patient know when PA#1 was assigned to him/her. She said Patient #1 was on his/her phone with someone, being loud and getting agitated and she asked the Patient not to speak like that on his/her phone in the overflow area. She said Patient#1 was threatening her and she called security who arrived and got in between her and the Patient. She said she told Patient #1 he/she needed to leave and would be seen at the Hospital. She said Patient #1 left the overflow room to talk to the charge nurse, came back, and security took her out to the waiting room. She said the provider did not see Patient #1. She said Patient #1 never mentioned pain to her, however, she could hear Patient #1 talking about being in pain to someone on his/her phone; she never messaged a provider for Patient #1.

During an interview with RN #1 on 4/29/25 at 12:15 P.M., she said she performed the triage assessment for Patient #1 on 4/25/25. She said Patient #1 had reported being hit in the nose while breaking up a fight and had pain at her nose. She said at that time Patient #1 did not need immediate attention, was not aggressive, and seemed appropriate to go to the overflow area in the ED as her acuity was assessed to be lower.

During an interview with PA #1 on 4/29/25 at 12:40 P.M., she said she assigned herself to Patient #1 on 4/25/25. She said she was on her way to see Patient #1, but she had to stop to see another patient first. She said she was not able to examine Patient #1 before she had left the ED. She said sometimes it can take time to have a provider see a patient in the ED based on capacity and availability of providers. She said RNs can message providers to request quicker evaluations for patients if they feel it is necessary to get a more urgent examination by a provider. She said she was never messaged about Patient #1 needing evaluation or any aggressive behaviors.

During an interview with security officer #1 on 4/29/25 at 1:15 P.M., he was called by RN #2 on 4/25/25 because Patient #1 was acting with threatening behaviors. He said when he arrived Patient #1 did make some verbal threats towards RN #2, and he put himself in between the Patient and RN #2. He said he told Patient #1 he/she had to leave the ED. He said after she left the ED and went to the waiting room, he spoke with him/her in the vestibule exiting the ED waiting room and the Patient apologized and left in a ride-service vehicle. He said security staff are trained in de-escalation to help manage difficult or aggressive behaviors with patients.

Review of the Hospital surveillance footage of the hall at the ED overflow room and the ED waiting room dated 4/25/25 indicated 2 security guards (including security officer #1) arrived at the overflow room, Patient #1 left the overflow room to cross the hall to the charge nurse area and returned to the overflow room. Patient #1 could be observed at the outside of the overflow room talking with the security staff. Security officer #1 could be seen pointing at the door exiting the ED to the waiting room. Patient #1 left the ED to the waiting room and entered the vestibule to the exit of the waiting room; security officer #1 entered the waiting room and then the vestibule and spoke with Patient #1; Patient #1 exited the building and was picked up by a car and left the Hospital.

The Hospital failed to ensure Patient #1 was examined by a medical provider after presenting to the Hospital's ED seeking emergency care.