HospitalInspections.org

Based on review of medical records, hospital policy and procedure, Medical and Dental Staff Bylaws and Rules and Regulations, hospital psychiatric order set, observations, and interviews, it was determined the facility failed to ensure:


1. An appropriate medical screening examination was provided.

2.. All individuals who presented to the ED received necessary stabilizing treatment.

This had the potential to affect all patients presenting to the ED.

Findings include:

Refer to Tags A 2406, and A 2407.

Based on review of hospital policy and procedure, observations and interview, it was determined the hospital failed to ensure signs specifying the rights of individuals regarding Emergency Medical Treatment and Labor Act (EMTALA), and signs indicating whether the hospital participates in the Medicaid program were posted in places likely to be noticed by all individuals entering the emergency department via the ambulance/ side entrance.

This deficient practice had the potential to affect all patients arriving at this hospital for emergency care via the ambulance/ side entrance.

Findings include:

Hospital Policy: EMTALA
Policy Number: None listed
Date Reviewed: 3/3/2021

...VII. Additional Requirements

A. Signage: WMC (Wiregrass Medical Center) must post one or more signs conspicuously in the Emergency Department, or in a place or places likely to be noticed by all individuals entering the Emergency Department, and by individuals waiting for examination and treatment in other areas (that is, entrance, admitting area... )...

A tour of the Emergency Department (ED) conducted on 4/8/24 at 12:10 PM with Employee Identifier (EI) # 3, Quality Director, revealed there were no signs posted at the ED ambulance/ side entrance.

An interview was conducted with EI # 3 during the tour, who confirmed there were no signs posted in the ambulance/ side entrance to the ED regarding the EMTALA laws, or whether the hospital participated in the Medicaid program.

Based on review of medical records (MR), hospital policy and procedure, City Police Department Incident Report, Emergency Medical Services Report (EMS), Medical and Dental Staff Bylaws and Rules and Regulations, hospital psych (psychiatric) order set, and interviews, it was determined the hospital failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for a patient presenting to the Emergency Department (ED) with Behavioral problems, abnormal blood pressure of 202/108, Systolic (upper number) greater than 120 and Diastolic number (lower number) greater than 80, and Tachycardia (fast heart rate), heart rate of 126 (Normal Heart Rate 60-100).

This affected Patient Identifier (PI) # 1, one of three records reviewed of patients designated as Left Without Being Seen, and had the potential to affect all patients presenting to the hospital ED.

Findings include:

Hospital Policy and Procedure: EMTALA (Emergency Medical Treatment and Active Labor Act)
Policy Number: None listed
Date Revised: 3/3/2021

...In general, EMTALA requires that, in the event an individual "comes to the emergency department" at WMC (Wiregrass Medical Center) (the "Emergency Department"), within the meaning of the statute, WMC must provide the individual with an appropriate medical screening examination...

...I.
...A. When an MSE Is Required: ...An individual will be deemed to have "come to the Emergency Department," within the meaning of EMTALA, in the following circumstances:

1. The individual presents at the Emergency Department and requests, or a request is made on his or her behalf, for examination or treatment for a medical condition. Even if no such request is made, WMC must provide the individual with an MSE if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition.

...C. Medical Screening Examination: When an MSE is required, WMC must screen an individual to determine, with reasonable clinical confidence, whether the individual has an EMC (Emergency Medical Condition). WMC must tailor each MSE to the particular individual's presenting signs and symptoms and utilize any ancillary services that are routinely available to the Emergency Department.

...2. Emergency Medical Condition: ...in the case of a psychiatric emergency, an EMC exists if an individual expresses suicidal or homicidal thoughts or gestures, or if the individual is dangerous to him/herself or others.

3. Ongoing Process: Not Equivalent to Triage. An MSE is not an isolated event; it is an ongoing process that typically begins, but does not end, with triage...


Medical and Dental Staff Bylaws and Rules and Regulations
Date Approved by Governing Body: 3/13/2019

...Section 7. Emergency Service Staff

The Emergency Service Staff shall consist of those physicians who are secured under arrangement... to provide emergency medical and surgical services for Wiregrass Medical Center.

Hospital Order Set: Psych
Order Number: None listed
Date Reviewed: None listed

Set Name

...Psych:

...Medical Urine Drug Screen

... Urinalysis

Review of PI # 1's MR revealed he/she was brought to the ED on 4/1/24 by the Geneva Police Department (PD), with a chief complaint of Behavioral Problem.

Triage and Nursing Assessment was documented at 1:55 PM, and included blood pressure 202/108, pulse 126, respiration rate 24, and pulse oximetry 100 %. Triage Acuity was documented as 3 (three) Urgent. Triage Disposition was EX 01 (Exam room 1) and time to room 2:15 PM.

Further review of the ED record revealed the five admission documents (consent to treat, advance directive, patient rights and responsibilities, guarantor agreement, and separate bills for services rendered notification) had "pt ams" (patient altered mental status) on the signature line.

Review of the Nursing Chart included documentation for General Assessment, Focused Assessment, and Examination.

Review of the Nursing Treatment Notes revealed the following documentation by the triage nurse:

"1:55 PM: City PD brought patient to ER (Emergency Room) due to behaviors. Officer's (officers) at bedside. Nurse attempting to triage.

1:58 PM: Patient unable to provide urine sample via urinal at this time.

2:00 PM Procedure: Catheter inserted.

2:07 PM VS (Vital Signs): BP (blood pressure) 202/108... HR (Heart Rate) 126... RR (Respiratory Rate) 24, O2 Sat (Oxygen Saturation) 100 %...

3:10 PM: Police Chief [Name] stated he/she was going to take patient from ER to police department.

3:20 PM: Patient left without being seen at this time.

Procedure Details:
Urinary Catheter- The catheter was inserted at 4/1/24 2:00 PM. The patient has a need for a catheterization due to urine sample. Notes: Attempted cath (catheter) at this time for urine sample for behavioral clearance protocol. Unable to obtain.

...Disposition:
LWBS (Left Without Being Seen)
LWBS The patient departed the facility at 4/1/24 3:20 PM. Notes: Patient left without being seen at this time with City Police Dept (Department)..."

Review of the Physician Chart notes revealed no documentation by Employee Identifier (EI) # 4, the ED physician, that PI # 1 was provided a medical screening examination for his/her presenting signs and symptoms of psychiatric behavioral problems, and his/her abnormal blood pressure and heart rate.

Review of the City Police Department Report (Incident Report) Narrative section, dated 4/2/2024 at 08:19 revealed in part, "PI # 1 (patient name) was advised that we would be taking him/her to Wiregrass Hospital in order to get him/her some help. PI # 1 willingly allowed myself and Officer (name) to put him/her in hand restraints, and we placed him/her in back of my patrol vehicle. On the way to the hospital, PI # 1 randomly became aggressive, yelling things that I could not understand. Once we arrived at the hospital, Officer (name) and I walked him/her in and set him/her on the bed inside the hospital. PI # 1 kept acting as if he/she would lunge at people, so Officer (name) and I held him/her by the shoulders. Once the nurses came in to assist PI # 1, he/she kept yelling at them and calling a "bitch" and saying he /she wasn't a nice guy/girl. The nurse instructed PI # 1 that he/she would have to pee, ta (to) which they assisted him/her, but he/she would not pee. They advised PI # 1 that they would be doing a catheter. After attempting the catheter, PI # 1 proceeded to kick... the nurse who attempted the catheter, into the wall. PI # 1 was then removed from the hospital and put into an ambulance where they took him/her to another Hospital... where he /her would receive further care."

The EMS report for PI # 1 dated 4/1/2024 at 4:57 PM was reviewed. The section of the note titled, "Patient Care Report Narrative" revealed in part, "Dispatched to the city PD (Police Department) per police chief request for a male/female pt. with AMS (Altered Mental Status). Arrived on scene and was met by the police chief who advised they placed pt under mental health and want him/her transported to Hospital B (receiving hospital). The police chief... advised that they had taken the pt to Wiregrass Medical Center for help when he/she kicked one of the nurses and they advised the police that they were not capable of treating the patient or had the resources to treat him/her per chief... The chief states that they signed him/her out of the hospital and brought him/her back to the PD and called EMS for transport. Chief... states that a police officer will accompany him /her and he/she will be in handcuffs for the transport due to his/her random moments of violence he /she has displayed several times throughout the day. One of the city... PD officers advised that he/she is diagnosed with schizophrenia but do not believe he/she has taken any medications. Pt was assisted into the ambulance where he /she was secured to the stretcher. City... PD Officer... remained in custody of the pt. Pt was alert but very confused. Pt appeared to be in psychosis state of mind. The pt displayed multiple emotions throughout transport. The pt's speech was incoherent majority of the time. Pt vitals were assessed and monitored during transport. Pt was monitored for any further changes en route. On arrival at Hospital B, report to nursing staff. Report given to RN (Registered Nurse). Witnessed... PD sign for transport since he/she is a mental health pt. of law enforcement. Witness nurse sign receiving care."

The medical record for PI # 1 from Hospital B was reviewed. The medical record revealed the Physician Assistant (PA) documented in part, "HPI (History of the Present Illness) Chief Complaint: Patient presents with Psychiatric Evaluation. EMS states, "He was just released from the jail... PD took him to Wiregrass for mental health eval (evaluation) and he kicked one of their nurses, they said they didn't have the resources there and sent him back with PD to bring him here. The police officer (name) with EMS (name of EMS company) accompanied pt back to the PD where he and the patient were picked up by EMS and brought here... he is not aggressive on evaluation, but he speaks flight of ideas and is delusional on questioning... Glasgow Coma Scale (tool used to objectively describe extent of impaired consciousness) Score 13 (mild brain injury)... Review of Systems: Psychiatric Behavioral: Positive for agitation, behavioral problems and confusion... Physical Exam... Neurological: Mental Status: He is alert. He is disoriented... Psychiatric: Mood and Affect: Affect is flat. Speech: Speech is rapid and pressured. Behavior: Behavior is withdrawn. Thought Content: Thought content is delusional. Cognition and Memory: Cognition is impaired, ED Course: ED Course... Clinical Impressions as of 4/1/24 7:33 PM Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality)... Medical Decision Making: Spoke with Psychiatrist (MD Name) who will accept pt to BMU (Behavioral Medicine Unit) for evaluation... will treat UTI (Urinary Tract Infection) in ED... Attending Physician: (Physician Name), MD Psychiatrist...History of present illness: ...30 y.o. (year old) with past history of schizoaffective disorder, PTSD (Post Traumatic Stress Disorder), and medication noncompliance... In the ED, patient received ceftriaxone for UTI, Hydroxyzine (medication used to help control anxiety and tension caused by nervous emotional conditions) and Zyprexa (medication used to treat several mental health conditions). Patient was admitted to the BMU for further evaluation and treatment.

The facility failed to ensure their EMTALA policy was followed as evidenced by failing to provide an appropriate medical screening examination, when a request was made on PI # 1's behalf by the city's police officers when presented to hospital's ED on 4/1/2024, for an examination and treatment of his medical conditions.

An interview was conducted on 4/8/24 at 12:26 PM with EI # 4, ED contract physician, who was working in the ED when PI # 1 presented to the ED on 4/1/24. The surveyor asked the ED physician if he/she remembered PI # 1. EI # 4 stated yes, but was not involved, and was busy with other patients. EI # 4 stated that he
/she remembered that Police were at the back door with PI # 1, and heard cursing and noise outburst. The nurse went to do the triage, and the nurse came out and said she/he was kicked. EI # 4 further stated, "I could hear screaming, I knew he/she was breathing and had a heartbeat. I knew he /she was OK." The surveyor asked the ED physician if PI # 1 received a medical screening examination, and the ED physician reported that no screening was done. The question was asked by the surveyor if PI # 1 should have received a medical screening examination? The ED physician indicated he/she did not know; and once the police said they were taking PI # 1, that was LWBS (Left Without Being Seen). EI # 4 stated, "They have the right to leave if they don't want to be seen, and no orders were written." EI # 4 stated he /she was unaware no paperwork was signed. The physician was also asked if he/she knew the intentions of the police when they left the hospital with PI # 1. The physician answered he/she was told they were taking the patient back to the precinct. EI # 4 knew the police were going to leave with PI # 1, and failed to perform medical screening exam.

An interview was conducted on 4/9/24 at 5:15 PM with the EI # 5, triage nurse, who was also in the ED when the patient presented to the ED on 4/1/24. EI # 5 verbalized that she/he remembered PI # 1, a psychiatric patient, as it was the first time EI # 5 had been assaulted. The City Police department brought him/her straight into the exam (examination) room in handcuffs. Three (3) police officers were there including the Chief. The patient was talking out of his/her head and could tell me his/her name, but not where he/she was. The medic got VS (Vital Signs) while I was trying to do questions. I went to get a urine, which is part of our psychiatric screening, the patient tried to urinate for approximately ten minutes, but could not. I then asked the patient if I could try obtaining the urine another way, and the patient was catheterized, but no urine was obtained. I turned around to de-glove and he /she kicked me in the shoulder, and I left the room. I called the Supervisor, Chief Nursing Officer (CNO). The Tech (Technician) called around looking for a bed, and the Medic stated to the chief, "You will need to leave an officer here." Chief said I am going to take him/her to the police station. The surveyor asked the question did the patient receive a medical screening examination, and EI# 5's answer was that no doctor saw the patient. The question also asked by the surveyor was "Where were the police going to the take the patient when they left the ED?" The nurse's answer was, "I don't know, just said he/she was going to the police station, and they were talking about several things, arrest, and another facility. So, the patient left without being seen."

EI # 5 revealed that the protocol for psychiatric patients is a urine drug screen, UA (Urinalysis), CXR (Chest X-ray), CMP (Comprehensive Metabolic Panel -measures blood level of glucose and other elements), CBC (Complete Blood Count, measures red blood cells, white blood cells and platelets in the blood), COVID test, and if HR (heart Rate) is up a cardiac screen. EI # 5 stated, "It's not an order set, our old system had one. The orders are usually verbal orders, then the Medical Doctor signs the chart." Despite this patient's presentation of abnormal heart rate and elevated blood pressure there was no cardiac screen order, and no medical interventions related to the patient's abnormal vital signs.

A telephone interview was conducted on 4/10/2024 at 1:13 PM with the City's Chief of Police. The surveyor asked the Chief did he/she remember PI #1, and he/she stated "Yes," and the reason for bringing him/her in was because they were called due to his/her irrational behavior, and he/she was transported to the hospital because he/she was violent. The surveyor asked if the physician had any interaction with PI # 1, the Chief answered that it did not get that far. The Chief was also asked if the hospital encouraged them to stay and have PI # 1 examined? The Chief answered, once that happened (kicked the nurse) and couldn't do a drug screen, I knew he/she couldn't get in anywhere, so I asked would I get in trouble just taking him/her to the station. They said no. The next question was did you tell anyone in the ED that you may take PI # 1 somewhere else? The Chief of Police answered that he/she was not sure, "...I just knew they couldn't keep him/her without a doing a drug screen. We deal with is all the time."

The Chief of Police also stated he/she never talked to the physician. After the patient assaulted the nurse, he/she stated he/she asked the CNO if he/she would get in trouble if they took the patient to the police station, and he/she stated she/he responded, "No." The Chief denied being asked to sign any paperwork before leaving and doesn't remember being asked to stay and let the doctor examine the patient first.

Further review revealed that after arriving at the PD, the police called an ambulance to pick up the patient and transport to Hospital B. An officer accompanied the patient in the ambulance. The patient was admitted to Hospital B for treatment.

An interview was conducted on 4/10/24 at 10:00 AM with EI # 2, CNO, who was at the hospital working on 4/1/24 when PI # 1 presented to the ED. The CNO indicated during the interview that she/he remembered PI # 1 because EI # 1 and EI #5 and the Police Chief were talking at the nurse's station. She/he was informed that EI # 5 had been kicked by PI # 1. She/he also stated the Chief stated they were going to take the patient back to the station. The surveyor asked the question did PI # 1 receive a medical screening examination on 4/1/2024 when he/she presented to the ED? The CNO stated the patient did not get a MSE by the ED physician.

A telephone interview was conducted on 4/10/24 at 9:30 AM with EI # 6, ED paramedic. EI # 6 verified that he/she was working in the ED on 4/1/2024 when PI # 1 presented to the ED. EI # 6 stated that he/she remembered PI # 1 because Law Enforcement brought him/her in handcuffs for us to evaluate and clearance for mental health. EI # 6 stated, "...While I was on the phone, he/she assaulted the nurse, I heard her/him scream and I ran in there I told the Chief, Y'all will have to have an officer here at all times for safety now, they said ok. They ended up leaving with PI # 1 in handcuffs."

An interview was conducted on 4/10/24 at 10:15 AM with EI # 8, ED technician, who was on duty when PI # 1 came to the ED on 4/1/24. EI # 8 stated that she/he remembered the Cops (Police) brought him/her in, but I was not involved in PI # 1's care. PI # 1 was put in an examination room. EI # 8 stated she/he remembered EI # 5 coming out and talked about being kicked, and the cops taking the patient back to the police station. EI # 8 also said that she/he did not remember and did not know if the patient received a medical screening examination.

An interview was conducted on 4/10/24 at 12:58 PM with EI # 2, who confirmed there was no MSE conducted by the physician on duty, and there was no documentation the patient, or the individuals acting on his/her behalf were informed of the risks and benefits associated with further examination and treatment. EI # 2 confirmed staff failed to obtain a signed refusal of exam and treatment, and the staff failed to document the refusal per policy. EI # 2 further confirmed only physicians may perform the MSE at WMC, per the Bylaws and Rules and Regulations.

Based on review of medical records (MR), hospital policy and procedure, and staff interviews, it was determined the hospital failed to offer the persons acting on behalf of the individual (Patient # 1) the risks and the benefits to the individual of the examination and treatment. Additionally, the facility failed to take all reasonable steps to secure a written informed refusal of the person acting on his/her behalf.

This affected Patient Identifier (PI) # 1, one of three records reviewed of patients designated as Left Without Being Seen, and had the potential to affect all patients presenting to the hospital ED.

Findings include:

Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act)
Policy Number: None Listed
Date Revised: 3/3/21

...In general, if WMC (Wiregrass Medical Center) determines that the individual has an EMC (Emergency Medical Condition), WMC must either provide necessary examination and treatment, within its capabilities, to stabilize the EMC, or provide for an appropriate transfer...

F.
...2. Leaving after Triage but before an MSE: In the event that, following triage but prior to receiving an MSE, an individual who has come to the Emergency Department attempts or demands to leave the hospital, or the individual (or if the individual is not capable of making an informed decision for him/herself, a person acting on the individual's behalf) refuses to consent to further examination or treatment, WMC personnel must (i) if possible, do a complete registration on the individual and chart relevant information; (ii) offer to provide the individual further examination and treatment as may be necessary to identify and stabilize an EMC; (iii) inform the individual (or the person acting on the individual's behalf) of the risks and benefits associated with further examination and treatment; (iv) if the individual (or the person acting on the individual's behalf) still refuses to consent to further examination and treatment, take all reasonable steps to obtain a signed, informed refusal of examination or treatment form from the individual (or the person acting on the individual's behalf), which form must indicate, at a minimum, that WMC personnel informed the individual (or the person acting on the individual's behalf) of the benefits or risks of examination and treatment, or both, if applicable; and (v) document the refusal accordingly...

Review of PI # 1's MR revealed he was brought to the ED on 4/1/24 by the Geneva Police Department (PD), with a chief complaint of Behavioral Problem.

Triage and Nursing Assessment was documented at 1:55 PM, and included blood pressure 202/108, pulse 126, respiration rate 24, and pulse oximetry 100 %. Triage Acuity was documented as 3 (three) Urgent. Triage Disposition was EX 01 (Exam room 1) and time to room 2:15 PM.

Review of the Nursing Chart included documentation for General Assessment, Focused Assessment, and Examination.

Review of the Nursing Treatment Notes revealed the following documentation by the triage nurse:

"1:55 PM: Geneva PD brought patient to ER (Emergency Room) due to behaviors. Officer's (officers) at bedside. Nurse attempting to triage.

1:58 PM: Patient unable to provide urine sample via urinal at this time.

2:00 PM Procedure: Catheter inserted.

2:07 PM VS (Vital Signs): BP (blood pressure) 202/108... HR (Heart Rate) 126... RR (Respiratory Rate) 24, O2 Sat (Oxygen Saturation) 100 %...

3:10 PM: Police Chief [Name] stated he/she was going to take patient from ER to police department.

3:20 PM: Patient left without being seen at this time.

Procedure Details:
Urinary Catheter- The catheter was inserted at 4/1/24 2:00 PM. The patient has a need for a catheterization due to urine sample. Notes: Attempted cath (catheter) at this time for urine sample for behavioral clearance protocol. Unable to obtain.

...Disposition:
LWBS (Left Without Being Seen)
LWBS. The patient departed the facility at 4/1/24 3:20 PM. Notes: Patient left without being seen at this time with Geneva Police Dept (Department)..."

Review of the Physician Chart notes revealed no documentation by hospital staff that the persons acting on PI # 1's behalf (Law Enforcement) were explained the risks and benefits of the examination and treatment.

On 4/9/23 at 12:26 PM, an interview was conducted with the ED physician EI # 4. The surveyor asked EI # 4, was PI # 1 or the officers advised of the risks and benefits of leaving without a medical screening examination. EI # 4 replied, not by me.

An interview was conducted on 4/10/24 at 12:58 PM with EI # 2, who confirmed there was no MSE, no documentation the patient, or the individuals acting on his/her behalf were informed of the risks and benefits associated with further examination and treatment. EI # 2 confirmed staff failed to obtain a signed refusal of exam and treatment, and the staff failed to document the refusal per policy.