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Based on medical record review, hospital policy review, review of security incident reports and staff interviews, the hospital failed to ensure all patients received a complete medical screening examination. This affected three of thirty medical records reviewed, (Patient #'s 8, 9, 10).

Findings included;

The medical record for Patient #8 was reviewed on 07/22/10. The medical record revealed Patient #8 presented to the emergency department at 4:51 P.M. The patient walked into the emergency department with complaints of his/her "nerves are shot, I've been exposed to mass amount of chemicals, I can't sleep". A triage assessment and vital signs were documented at 5:08 P.M. by the triage Registered Nurse (RN). The triage note indicated the patient denies suicidal or homicidal thoughts. The medical record revealed the patient left without treatment at 6:54 P.M. The medical record lacked evidence of a medical screening examination prior to the patient leaving.

Surveyors were presented with an incident report completed by security staff of the hospital. The incident report revealed the security officer was notified by a nurse that security was needed in the waiting room. The security officer reported witnessing Patient #8 "yelling and waving a fist around". The security officer requested additional officers and proceeded to approach the patient. The incident report stated the patient saw the officer approaching and exited the building via the emergency department doors. The officer "continued to pursue" the patient as additional officers arrived. A second officer then detained the patient and called for the local police department. The report indicated the local police department arrived shortly after and took Patient #8 into custody for disorderly conduct. A statement was attached to this report which was type written and signed by Employee E, a hospital registrar. The statement was dated 07/14/10 and stated the person accompanying Patient #8 had approached him/her and stated the patient was becoming agitated and that the patient was "about to go off." The statement further read; "after speaking with a nurse about the situation I returned to the waiting room, moments later the patient started screaming 'f*** you all, y'all are supposed to be doctors and you can't fix any f***ing problems!'. (Patient #8) proceeded to throw his hat at the nurse's station and then stormed out the front door."

The medical record lacked evidence the medical staff attempted to calm the patient prior to security being called. The medical record lacked evidence a clinical staff member was present at the time the patient was approached by security and detained.

Hospital policy number SE01.00, titled "Assistance Alert" was reviewed on 07/23/10. The policy outlined the procedures to be taken for dealing with patients who present an immediate or potential threat to self, other patients/visitors, or staff members. The procedure section, number one, stated staff members are to immediately notify security of the situation as indicated, and may attempt the following interventions if the situation allows; verbal intervention, decrease stimulation, limit setting, medication. Number two stated if the patient fails to respond to the above interventions, or if the patient is potentially/actively assaultive, a staff member will make the decision to summon additional staff assistance. Number four stated if the assistance alert occurs in a clinical area, the responding staff will designate a trained clinical staff member (charge nurse, staff registered nurse, or designee) who will direct all interventions by all staff responding.

An interview was conducted with Employee C on 07/22/10 at 11:15 A.M. Employee C was one of the security officers that responded on 07/14/10. Employee C stated he/she immediately responded to the emergency department waiting room and noted the patient and security officer had gone outside. Employee C went outside and noted Patient #8 sitting on the curb with a security officer. Employee C stated the patient was placed in handcuffs and calmed with verbal intervention by Employee C. Employee C stated the patient wasn't making any sense, was talking about transmission fluid, had been kicked out of several hospitals. Employee C described the patient as still loud, but no longer combative. Employee C stated the patient's significant other then came outside and the patient again became agitated and combative. The patient's significant other was assisted inside and the police department called.

An interview was conducted with Employee F on 07/23/10 at 2:39 P.M. Employee F was the security officer who initially responded to the waiting room of the emergency department for a reported disturbance by Patient #8 on 07/14/10. Employee F stated the patient was anxious but cooperative. Employee F stated at one point he returned to the waiting room with the significant other of Patient #8 and upon returning outside, the patient had been handcuffed by Employee C. Employee F stated the patient was cooperative, was apologetic about the incident but alternately angry regarding his wait in the emergency department. Employee F stated the decision was made to call the local police department due to the outburst in the waiting room. Upon further questioning by surveyors, Employee F stated the patient had made a statement to Employee C in which the patient requested the security guard to shoot him. Employee F confirmed this information was relayed to the local police department upon their arrival but medical staff had not been present to witness this statement.

The patient's medical record from another hospital was reviewed. This medical record contained evidence of a statement of belief completed by the local police department to place the patient on a seventy two hour psychiatric hold due to a belief the patient was at risk of harming himself or others. The statement of belief stated the reason for the psychiatric hold was because the patient had requested security officers to shoot him. Employee A, the emergency department director, was interviewed on 07/23/10 at 4:00 P.M., regarding this statement by the patient. Employee A stated the patient would have been considered a suicide risk upon making this statement and had medical staff known, the patient would have been detained at the hospital for psychiatric treatment. Patient #8 was admitted to the second hospital and placed on a psychiatric unit. The psychiatric services initial assessment described the patient as having auditory hallucinations, disorganized thought processes with agitation and restlessness at 10:30 P.M. The emergency services nursing record also described the patient as calm and cooperative with the interview process at 6:30 P.M.

Surveyors requested a copy of the police report for the incident. On 07/23/10, surveyors were told a police report was not available, but were presented with a copy of a mental health response report. The details section of the report stated the patient was calm upon arrival of the police officers. The report stated the patient admitted to the police that he/she wanted security to shoot him/her. The report stated the criminal charges against Patient #8 were "none". Employee B stated, on 07/23/10 at 4:30 P.M., at the time the report was given to surveyors, the hospital was planning to pursue criminal charges against Patient #8 in regard to the incident in the waiting room.

The hospital policy regarding "The Emergency Medical Treatment and Active Labor Act", policy number 05.00 was reviewed on 07/23/10. The policy defined transfer as the movement of an individual outside the hospital's facilities at the direction of any person employed by the hospital.

The medical record for Patient #9 was reviewed on 07/23/10. Patient #9 presented to the emergency department on 07/01/10 at 4:28 A.M. for complaints of abdominal pain. The medical record revealed the patient was triaged at 4:34 A.M. and placed in a room at 4:43 A.M. The medical record further revealed the patient was seen by an emergency room physician at 4:55 A.M. The emergency department did a review of systems and ordered a one liter bolus of intravenous fluids, an abdominal CT scan and lab tests including lipase level, thyroid stimulating hormone level, liver function panel, ethanol (alcohol) level, a complete blood count and a metabolic panel. The medical record contained a notation at 5:03 A.M. which stated the patient was refusing to get undressed, cussing at the RN (registered nurse), trying to hit the RN, refusing to cooperate with care. Security called to escort patient out of the emergency department. Patient was escorted out per security. The medical record lacked information regarding attempts by clinical staff to de-escalate the patient's behavior by verbal intervention, decreased stimuli, limiting the setting or medication as required by hospital policy. The medical record revealed the lab tests as well as the CT scan of the abdomen were not performed. The medical record lacked evidence regarding the intravenous fluids. The medical record lacked evidence intravenous access was started prior to the patient being escorted out of the emergency department. The medical record contained evidence of an emergency room report dictated by Employee G, an emergency department physician. The emergency room report stated the patient had been drinking "this morning" as he/she smelled strongly of alcohol. The section titled medical decision making stated; "workup here was going to be a detox workup plus a CT of the abdomen and pelvis to evaluate for kidney stone, but the patient became belligerent with staff here in fact allegedly he tried to strike one of our coworkers and at that point, it was deemed the patient was going to be escorted off the premises without any further workup." The emergency room report lacked evidence of other measures taken to calm the patient or gain compliance before the patient was escorted out by security staff.

An incident report was reviewed on 07/23/10. The incident report was dated 07/01/10 and contained the name of Patient #9. The details of the incident stated three officers responded to assist staff with the patient. Upon their arrival, the staff was advising the patient he needed to leave because he was not cooperating and was being abusive toward the doctor and the staff. The patient was recognized by one of the officers as having been to the emergency department three times in the past week. The reason for these other visits was not noted, nor were they mentioned in the patient's medical record. The report stated, "this officer advised the subject to get up and leave. Subject proceeded out of the building and began to act out as if he was in pain. Subject was advised that his actions would not be tolerated. Subject was escorted to Clifton Avenue after several attempts to sit down in the driveway. Subject left the area stated he was going to call the police to come and arrest this officer. Subject then sat down again at the Clifton Avenue sidewalk. At this time, all 3 officers began to walk back to the building. After a few minutes, the subject got up and started to walk down Clifton Avenue." The medical record lacked evidence the patient was accompanied by any other individual. The medical record and the incident report lacked evidence attempts by hospital staff to ensure the patient's safety when he/she began to walk down the street.

The medical record for Patient #10 was reviewed on 07/23/10. The medical record revealed the patient presented to the emergency department on 06/25/10, for complaints of a painful knot in her right breast and fever. The medical record revealed the patient arrived at the hospital at 9:41 P.M., was triaged at 10:04 P.M. and placed in a room at 10:10 P.M. The medical record contained evidence the patient was seen by Employee H, an emergency room physician at 12:05 A.M. The emergency room report completed by this physician stated he/she consulted with surgery for an evaluation of the patient to determine if a need existed for the area to be surgically opened and drained. The report continued, "In the interim, however, screening labs had been ordered on the patient, results already noted along with the urinalysis. Apparently during this interaction with the nursing staff, the patient became belligerent and threatening and I was notified. I instructed the nursing staff to contact security to escort the patient out of the emergency department in light of (Patient's) belligerent and threatening behavior." The medical record lacked evidence the patient was evaluated by a surgeon or a determination had been made for treatment. The medical record lacked documentation of attempts by clinical staff to calm the patient or to follow the hospital policy regarding interventions defined to be used to attempt to calm the patient. The physician's impression of the patient's illness was listed as "acute breast abscess", although the medical record lacked evidence discharge instructions were given to the patient regarding any need for antibiotics or further follow up.

The medical record revealed a nursing note on 06/26/10 at 12:39 A.M., which stated the nurse went to the bedside to get a urine specimen and introduced him/herself. The patient's companion asked if the physician would come back to the room. The nurse informed the companion the physician would be back after lab results come back. The patient then stated, "all of these b****es got smart mouths" and "I will slap that b**** in the mouth" Security was then called to the bedside as well as the charge nurse. The next nurse's note was at 12:44 A.M. and stated Employee H was updated on threat to staff and the patient's belligerent behavior. Per Employee H, the patient was to be escorted off the unit with security. The note stated the patient was notified that threats are taken seriously and (are) not tolerated at (hospital). Patient dressed, saline lock (for intravenous access) was discontinued and the patient was escorted out of the unit.

An incident report, completed by Employee C regarding the incident with Patient #10, was reviewed on 07/23/10. The incident report stated the patient was observed to be disrobed and being very loud upon entrance of this male security guard into the female patient's room. The report stated the patient was advised to put her shirt on and immediately began to cuss at the officer and "moved towards my direction." The report does not state if the patient's behavior was threatening toward the officer. The officer then called for backup and two additional security guards arrived on the scene and the patient was escorted off the property. The reported stated this was "Per Doctors orders". The incident report lacked evidence of the patient's state of dress at that time. The report stated the patient remained disruptive and combative and the patient and the patient's family made several threats toward the officer while being walked to their car. The nature of these threats were not documented.

In an interview conducted on 07/23/10 at 3:50 P.M., Employee I stated, "You have to behave yourself when you come or you have to leave." Employee I further stated, "We have a right to take action, you will be asked to leave" Employee I stated this was part of the hospital's patient rights policy. The "Patient Rights" policy was reviewed on 07/23/10, but lacked evidence of Employee I's statement.

This deficiency substantiates complaint number OH00056397.