HospitalInspections.org

An unannounced onsite EMTALA investigation was conducted on January 24, 2013 for complaint numbered TN00031067. The findings of the investigation were forwarded to the CMS Regional office in Atlanta, Georgia.

The hospital's Chief Executve Officer was notified by the CMS Regional Office on June 11, 2013, by overnight mail that deficiencies were cited, but the hospital had identified the violation on its own, took effective corrective action prior to the investigation, and has had no violations for the past six months.

Based on review of a facility report, record reviews, policy reviews, and interviews, the facility failed to meet the requirements of the Emergency Medical Treatment and Labor Act for one (#26) patient of twenty-six Emergency Department (ED) patients reviewed.

Refer to A-2405: The hospital is to maintain a central log on each individual who comes to the emergency department seeking assistance;

Refer to A-2406: The hospital must provide an appropriate medical screening examination within the capability of the hospital's emergency room to determine if an emergency medical condition exists.

Refer to A-2407: The hospital must provide within it's capabilities further medical examination and treatment as required to stabalize the medical condition.

Refer to A-2409: The hospital may not transfer individuals unless the transfer is appropriate; the individual requests the transfer; that the medical benefits outweigh the risks of the transfer and that the transfer is provided through qualified personnel.

Based on review of a facility report, record review, policy review, and interviews, the facility failed to document in the Emergency Department (ED) Central Log one (#26) patient presenting to the ED for examination and treatment, of twenty-six ED patients reviewed.

The findings included:

Review of a letter from the facility (Hospital #1), written to the Department of Health (DoH), dated December 21, 2012, revealed the facility, "wished to self-report...a potential violation of the Emergency Medical Treatment and Labor Act..."

Further review of the letter revealed Patient #26 was brought to Hospital #1's satellite facility's Emergency Department (ED) on December 18, 2012, at approximately 1:45 a.m., by family members and friends for complaint of possible drug ingestion and behaving "wild"

Further review of the letter revealed Patient #26, "...slapping her boyfriend...refusing to get out of the car...cursing...belligerent...fighting...head butted RN1 in the stomach...running...cursing RN1 and slapped RN1 in the face...kicked the security officer in the arm..."

Further review of the letter revealed Patient #26 was placed in a wheelchair and staff attempted to take the patient into the ED with the patient cursing and yelling at the family members. The letter revealed that before staff could transport the patient into the ED, the patient, "began cursing RN1 and slapped RN1 in the face...the patient's boyfriend restrained the patient...when the security officer tried to talk to the patient, the patient kicked the security officer in the arm."

Further review of the letter revealed, "RN1 had called the...Police Department for assistance...When the...Police Officers arrived they asked RN1 what...wanted them to do with the patient...RN1 indicated the ED was full and the patient was too violent to be brought into the ED." The letter also stated, "The Police Officers advised the patient and those that brought...to the ED that they would have to leave the property or the patient would be arrested".

Further review of the letter revealed, "The patient's friends placed the patient in the car and transported the patient to (Hospital #2) for treatment." The letter also stated, "The patient was admitted...with diagnosis of...altered mental status...hypokalemia...alcohol poisoning."

Further review of the letter revealed Hospital #1, "...failed to enter the patient's name in the ED Central Log as a patient presenting to the ED for which examination and treatment was requested..."

Further review of the letter revealed, "A late manual entry regarding this incident has been made in the...ED Central Log."

Review of the ED log pages dated December 18, 2012, revealed no documentation of Patient #26 presenting to the ED that date. Review of an addendum to the ED log, run date December 31, 2012, revealed Patient #26 presented to the ED on December 18, 2012, at 2:00 a.m. for "Evaluation". Further review of the addendum revealed the patient's disposition was documented as, "left prior to triage".

Review of facility policy titled, "EMTALA-Definitions and General Requirement" effective date September 1, 2012, revealed, " Central Log is a log that a hospital is required to maintain on each individual who comes to the emergency department seeking assistance...Log the individual into the Central Log."

Interview with the ED Director, on January 22, 2013, at 2:15 p.m., in the Administration Conference Room of Hospital #1's satellite facility, revealed hospital policy required Patient #26's name, date and time of presentation, reason for visit, and disposition, be documented on the ED Log. Further interview with the ED Director confirmed the ED staff did not follow facility policies, by failing to enter Patient #26 into the Central Log on December 18, 2012. Further interview revealed the facility had added an addendum to the Central ED Log which included Patient #26, as part of the facility's corrective actions.

Interview with RN#2, by telephone, on January 24, 2013, at 11:15 a.m., revealed this nurse went out to assist RN#1 with transporting Patient #26 into the ED. RN#2 stated the patient did not want to come inside the ED and was resisting verbally and physically. RN#2 stated the patient fought with family and staff. RN#2 stated the patient appeared "manic" and "paranoid". RN #2 stated he saw the patient "head butt" RN#1 in the stomach, and later "slap" RN#1 in the face. RN#2 stated he saw the patient also kick the security officer in the chest area. RN#2 stated the patient was being restrained outside the ED by a male friend when the local police arrived. RN#2 stated the police told the patient to, "calm down and be seen, be arrested, or leave." RN#2 stated the patient and family/friends got in their car and left. RN#2 confirmed the patient visit to the ED was not documented in the ED Central Log.

Interview with RN#1, by telephone, on January 24, 2013, at 3:20 p.m. revealed the nurse remembered the incident with Patient #26 on December 18, 2012. RN #1 stated, "I went out to help a patient out of a car and the patient's friend told me I had to get the patient out of the car, I told the friend, the patient had to come out of car on their own". RN#1 stated Patient #26 was, "beating on a man in the back seat of the car when I arrived, and the patient was saying over and over 'I don't want to be here, and why did you bring me here?" RN#1 also stated, "the patient was coaxed out of the car and was in the wheelchair and when I unlocked the brakes the patient rushed at me and tried to tackle me. The patient then ran to the north side of the hospital where the male friend caught her and they fought on the ground. I went and called security and ...police department. We put her back in wheelchair and almost got inside the ED when patient jumped up and slapped me on the face. The patient's male friend restrained the patient again, and they struggled outside the ED." RN#1 stated, "I explained that the patient had a right to a medical examination, but that the patient would have to come into the ED. I told the patient and family that the patient could come into the ED and be seen, or they could take the patient home." RN#1 stated the patient was never told to go to another facility, and confirmed the patient was never examined by anyone at Hospital #1. RN#1 stated the ED physician was never aware the patient had presented to the ED. RN #1 confirmed the local police arrived and told the patient and family, "the patient could calm down and be seen, leave or be arrested, and they decided to leave." RN#1 stated the patient was not added to the ED log.

The hospital took the following actions:

Hospital #1 investigated this incident, and reported the findings of the incident to the Department of Health. Hospital #1's investigation found the ED staff did not follow the Hospital's policies and practices on December 18, 2012. Hospital #1 implemented a plan of correction which included:

1. Counseled staff involved in the incident on EMTALA requirements and management of violent patients.
2. Educated all ED and Labor/Delivery staff at the main hospital and all satellites on EMTALA requirements and management of violent patients. Security officers were also included in the training. All staff were also educated on the facility's Chain of Command Policy and the Violent Patient Policy.
3. An "Addendum" was added to the ED Log on 12/31/12 that included Patient #26's name.

Documentation of staff's attendance and completion of the training was provided to the Surveyor. ED staff interviewed during the compliant investigation confirmed the training had occurred and demonstrated knowledge of EMTALA requirements.

Interview with the Market Director of Quality, by telephone, confirmed facility compliance with the EMTALA requirements and other facility policies is being monitored by monthly chart and ED Log reviews, and of all incidents of patients leaving the ED without a Medical Screening Exam are investigated.

Based on review of a facility report, record review, policy review, and interviews, the facility failed to provide an appropriate medical screening examination for one (#26) patient of twenty-six patients reviewed.

The findings included:

Review of a letter from the facility (Hospital #1), written to the Department of Health (DoH), dated December 21, 2012, revealed the facility, "wished to self-report...a potential violation of the Emergency Medical Treatment and Labor Act..."

Further review of the letter revealed Patient #26 was brought to Hospital #1's satellite facility's Emergency Department (ED) on December 18, 2012, at approximately 1:45 a.m., by family members and friends for complaint of possible drug ingestion and behaving "wild"

Further review of the letter revealed Patient #26, "...slapping her boyfriend...refusing to get out of the car...cursing...belligerent...fighting...head butted RN1 in the stomach...running...cursing RN1 and slapped RN1 in the face...kicked the security officer in the arm..."

Further review of the letter revealed Patient #26 was placed in a wheelchair and staff attempted to take the patient into the ED with the patient cursing and yelling at the family members. The letter revealed that before staff could transport the patient into the ED, the patient, "began cursing RN1 and slapped RN1 in the face...the patient's boyfriend restrained the patient...when the security officer tried to talk to the patient, the patient kicked the security officer in the arm."

Further review of the letter revealed, "RN1 had called the...Police Department for assistance...When the...Police Officers arrived they asked RN1 what...wanted them to do with the patient...RN1 indicated the ED was full and the patient was too violent to be brought into the ED." The letter also stated, "The Police Officers advised the patient and those that brought...to the ED that they would have to leave the property or the patient would be arrested".

Further review of the letter revealed, "The patient's friends placed the patient in the car and transported the patient to (Hospital #2) for treatment." The letter also stated, "The patient was admitted...with diagnosis of...altered mental status...hypokalemia...alcohol poisoning."

Further review of the letter revealed Hospital #1, "...failed to provide the patient with a medical screening examination regarding the patient's behavior and emergency medical condition..."

Review of the ED log and ED records revealed no documentation of Patient #26 being examined or treated in the ED of Hospital #1.

Review of the medical record from Hospital #2, revealed Patient #26 presented to the ED on December 18, 2012, at 2:35 a.m. with complaint of Altered Mental Status. Review of the ED Triage Notes from Hospital #2, revealed, "pt (patient) was brought in by family ...was given unknown drugs, was taken to (Hospital #1) and they wouldn't take...so...came here. Pt is combative, altered. Pt immediately brought back to room...had to restrain pt for safety..."

Review of the physician's admitting history and physical from Hospital #2, dated December 18, 2012, revealed , "...took some unknown substances which rendered...confused and agitated...had to be physically and chemically restrained...alcohol level 304 (toxic above 400)." Further review of the history and physical revealed, "admit to ICU (Intensive Care Unit)" with diagnosis of: Altered Mental Status, Alcohol Intoxication, Unknown Drug Consumption, Hypokalemia, and Dehydration".

Review of RN#1's written statement dated December 18, 2012, revealed the nurse went outside the ED on December 18, 2012, to assist a patient out of a car. Further review of RN #1's statement revealed, "...is slapping boyfriend and refuses to get out of car...I informed them I would not get...out of the vehicle and...would need to exit on...own." The statement also revealed, "...charged out of the wheelchair and head butted me in the stomach...then took off running toward the north side of the hospital...boyfriend chased...tripped and fell...I noticed abrasions to left knee ...attempted to approach...again placed...in the wheelchair...we got up ramp ...almost to ER (Emergency Room) door when...began cursing and yelling at the two women who transported...here...then slapped me across the face...then was pulled out of wheelchair by...boyfriend onto the ground..." Further review of the statement revealed RN#1 called the local police department (PD) and when the police arrive they find, "the boyfriend has the pt in a headlock because...is still yelling and cussing at everyone and striking out at the security guard..." Further review of the written statement revealed the police, "told them to leave the property or...would be arrested...I informed PD that...was too dangerous to bring back into the ER because we are completely full and the...is too violent..."

Review of facility policy titled, "EMTALA-Definitions and General Requirement" effective date September 1, 2012, revealed, "...an emergency department must provide to any individual...who comes to the emergency department and appropriate Medical Screening Examination".

Review of facility policy titled, "Emergency Department-Combative or Difficult to Manage Patient", reviewed date October 2011, revealed, "Patients who are difficult to manage, due to alcohol, drugs, or emotional problems, will be treated with care and dignity in a safe and secure environment. Staff are trained on how to care for and interact with combative or difficult patients..."

Interview with Security Officer #1 (SO#1), on January 22, 2013, at 1:05 pm, in the Administration Conference Room, revealed the officer recalled the incident involving Patient #26 on December 18, 2012. Interview revealed SO#1 was called to the ED to meet RN #1 in the ED Lobby. SO#1 stated there was loud arguing outside the ED, and the officer went outside and saw RN #1 and Patient #26 "arguing". The security officer stated RN#1 and family tried to calm the patient, but the patient became irate and at one time a male friend or family member was physically restraining the patient. The security officer stated the patient kicked the officer in the right arm and slapped RN#1 in the face, and was "very out of control". The security officer stated the local police arrived and told the patient to leave. The security officer stated the patient left in a car with the family and/or friends. The security officer confirmed the patient never entered the ED.

Interview with the ED Director, on January 22, 2013, at 2:15 p.m., in the Administration Conference Room of Hospital #1's satellite facility, revealed hospital policy required Patient #26 be brought into the ED and provided a Medical Screening Examination . Further interview with the ED Director confirmed the ED staff did not follow facility policies, in regard to Patient #26's treatment on December 18, 2012.

Interview, on January 22, 2013, at 3:00 p.m. in the ED of Hospital #1's satellite facility, with MD#1, the physician working the ED of Hospital #1, when Patient #26 presented on December 18, 2012, revealed MD#1 did not see or examine the patient.

Interview with RN#2, by telephone, on January 24, 2013, at 11:15 a.m., revealed this nurse went out to assist RN#1 with transporting Patient #26 into the ED. RN#2 stated the patient did not want to come inside the ED and was resisting verbally and physically. RN#2 stated the patient fought with family and staff. RN#2 stated the patient appeared "manic" and "paranoid". RN #2 stated he saw the patient "head butt" RN#1 in the stomach, and later "slap" RN#1 in the face. RN#2 stated he saw the patient also kick the security officer in the chest area. RN#2 stated the patient was being restrained outside the ED by a male friend when the local police arrived. RN#2 stated the police told the patient to, "calm down and be seen, be arrested, or leave."RN#2 stated the patient and family/friends got in their car and left. RN#2 confirmed the patient was not given a medical screening examination and did not sign out AMA.

Interview with RN#1, by telephone, on January 24, 2013, at 3:20 p.m. revealed the nurse remembered the incident with Patient #26 on December 18, 2012. RN #1 stated, "I went out to help a patient out of a car and the patient's friend told me I had to get the patient out of the car, I told the friend, the patient had to come out of car on their own". RN#1 stated Patient #26 was, "beating on a man in the back seat of the car when I arrived, and the patient was saying over and over 'I don't want to be here, and why did you bring me here?" RN#1 also stated, "the patient was coaxed out of the car and was in the wheelchair and when I unlocked the brakes the patient rushed at me and tried to tackle me. The patient then ran to the north side of the hospital where the male friend caught her and they fought on the ground. I went and called security and...police department. We put her back in wheelchair and almost got inside the ED when patient jumped up and slapped me on the face. The patient's male friend restrained the patient again, and they struggled outside the ED." RN#1 stated, "I explained that the patient had a right to a medical examination, but that the patient would have to come into the ED. I told the patient and family that the patient could come into the ED and be seen, or they could take the patient home." RN#1 stated the patient was never told to go to another facility, and confirmed the patient was never examined by anyone at Hospital #1. RN#1 stated the ED physician was never aware the patient had presented to the ED. RN #1 confirmed the local police arrived and told the patient and family, "the patient could calm down and be seen, leave or be arrested, and they decided to leave." RN#1 stated the patient was not added to the ED log and the patient did not sign a leaving Against Medical Advise (AMA) release.

The hospital took the following actions:

Hospital #1 investigated this incident, and reported the findings of the incident to the Department of Health. Hospital #1's investigation found the ED staff did not follow the Hospital's policies and practices on December 18, 2012. Hospital #1 implemented a plan of correction which included:

1. Counseled staff involved in the incident on EMTALA requirements and management of violent patients.
2. Educated all ED and Labor/Delivery staff at the main hospital and all satellites on EMTALA requirements and management of violent patients. Security officers were also included in the training. All staff were also educated on the facility's Chain of Command Policy and the Violent Patient Policy.
3. An "Addendum" was added to the ED Log on 12/31/12 that included Patient #26's name.

Documentation of staff's attendance and completion of the training was provided to the Surveyor. ED staff interviewed during the compliant investigation confirmed the training had occurred and demonstrated knowledge of EMTALA requirements.

Interview with the Market Director of Quality, by telephone, confirmed facility compliance with the EMTALA requirements and other facility policies is being monitored by monthly chart and ED Log reviews, and of all incidents of patients leaving the ED without a Medical Screening Exam are investigated.

Based on review of a facility report, record review, policy review, and interviews, the facility failed to provide treatment to stabilze the medical condition of one (#26) patient of twenty-six patients reviewed.

The findings included:

Review of a letter from the facility (Hospital #1), written to the Department of Health (DoH), dated December 21, 2012, revealed the facility, "wished to self-report...a potential violation of the Emergency Medical Treatment and Labor Act..."

Further review of the letter revealed Patient #26 was brought to Hospital #1's satellite facility's Emergency Department (ED) on December 18, 2012, at approximately 1:45 a.m., by family members and friends for complaint of possible drug ingestion and behaving "wild"

Further review of the letter revealed Patient #26, "...slapping her boyfriend...refusing to get out of the car...cursing...belligerent...fighting...head butted RN1 in the stomach...running...cursing RN1 and slapped RN1 in the face...kicked the security officer in the arm..."

Further review of the letter revealed Patient #26 was placed in a wheelchair and staff attempted to take the patient into the ED with the patient cursing and yelling at the family members. The letter revealed that before staff could transport the patient into the ED, the patient, "began cursing RN1 and slapped RN1 in the face...the patient's boyfriend restrained the patient...when the security officer tried to talk to the patient, the patient kicked the security officer in the arm."

Further review of the letter revealed, "RN1 had called the...Police Department for assistance...When the...Police Officers arrived they asked RN1 what...wanted them to do with the patient...RN1 indicated the ED was full and the patient was too violent to be brought into the ED." The letter also stated, "The Police Officers advised the patient and those that brought...to the ED that they would have to leave the property or the patient would be arrested".

Further review of the letter revealed, "The patient's friends placed the patient in the car and transported the patient to (Hospital #2) for treatment." The letter also stated, "The patient was admitted...with diagnosis of...altered mental status...hypokalemia...alcohol poisoning."

Further review of the letter revealed Hospital #1, "...failed to stabilize the patient's emergency medical condition..."

Review of the ED log and ED records revealed no documentation of Patient #26 being examined or treated in the ED of Hospital #1.

Review of the medical record from Hospital #2, revealed Patient #26 presented to the ED on December 18, 2012, at 2:35 a.m. with complaint of Altered Mental Status. Review of the ED Triage Notes from Hospital #2, revealed, "pt (patient) was brought in by family...was given unknown drugs, was taken to (Hospital #1) and they wouldn't take...so...came here. Pt is combative, altered. Pt immediately brought back to room...had to restrain pt for safety..."

Review of the physician's admitting history and physical from Hospital #2, dated December 18, 2012, revealed , "...took some unknown substances which rendered...confused and agitated...had to be physically and chemically restrained...alcohol level 304 (toxic above 400)." Further review of the history and physical revealed, "admit to ICU (Intensive Care Unit)" with diagnosis of: Altered Mental Status, Alcohol Intoxication, Unknown Drug Consumption, Hypokalemia, and Dehydration".

Review of RN#1's written statement dated December 18, 2012, revealed the nurse went outside the ED on December 18, 2012, to assist a patient out of a car. Further review of RN #1's statement revealed, "...is slapping boyfriend and refuses to get out of car...I informed them I would not get...out of the vehicle and...would need to exit on...own." The statement also revealed, "...charged out of the wheelchair and head butted me in the stomach...then took off running toward the north side of the hospital...boyfriend chased...tripped and fell...I noticed abrasions to left knee...attempted to approach...again placed...in the wheelchair...we got up ramp...almost to ER (Emergency Room) door when...began cursing and yelling at the two women who transported...here ...then slapped me across the face ...then was pulled out of wheelchair by...boyfriend onto the ground..." Further review of the statement revealed RN#1 called the local police department (PD) and when the police arrive they find, "the boyfriend has the pt in a headlock because...is still yelling and cussing at everyone and striking out at the security guard ..." Further review of the written statement revealed the police, "told them to leave the property or...would be arrested...I informed PD that...was too dangerous to bring back into the ER because we are completely full and the...is too violent..." There is no documentation in the written statement of the patient being informed of risks regarding leaving without a medical examination or being asked to signed an informed refusal of treatment and/or leaving against medical advise (AMA) consent form.

Review of facility policy titled, "EMTALA-Definitions and General Requirement" effective date September 1, 2012, revealed, "...provide necessary stablizing treatment to the individual or provide for an appropriate transfer...Obtain or attempt to obtain in writing an informed refusal of examination or treatment...in the case of an individual who refuses..."

Review of facility policy titled, "Emergency Department-Combative or Difficult to Manage Patient", reviewed date October 2011, revealed, "Patients who are difficult to manage, due to alcohol, drugs, or emotional problems, will be treated with care and dignity in a safe and secure environment. Staff are trained on how to care for and interact with combative or difficult patients ..."

Interview with Security Officer #1 (SO#1), on January 22, 2013, at 1:05 pm, in the Administration Conference Room, revealed the officer recalled the incident involving Patient #26 on December 18, 2012. Interview revealed SO#1 was called to the ED to meet RN #1 in the ED Lobby. SO#1 stated there was loud arguing outside the ED, and the officer went outside and saw RN #1 and Patient #26 "arguing". The security officer stated RN#1 and family tried to calm the patient, but the patient became irate and at one time a male friend or family member was physically restraining the patient. The security officer stated the patient kicked the officer in the right arm and slapped RN#1 in the face, and was "very out of control". The security officer stated the local police arrived and told the patient to leave. The security officer stated the patient left in a car with the family and/or friends. The security officer confirmed the patient never entered the ED.

Interview with the ED Director, on January 22, 2013, at 2:15 p.m., in the Administration Conference Room of Hospital #1's satellite facility, revealed hospital policy required Patient #26 be brought into the ED, provided a Medical Screening Examination, and provided stabilizing treatment if needed. Further interview with the ED Director confirmed the ED staff did not follow facility policies, in regard to Patient #26's treatment on December 18, 2012.

Interview, on January 22, 2013, at 3:00 p.m. in the ED of Hospital #1's satellite facility, with MD#1, the physician working the ED of Hospital #1, when Patient #26 presented on December 18, 2012, revealed MD#1 did not examine or treat the patient.

Interview with RN#2, by telephone, on January 24, 2013, at 11:15 a.m., revealed this nurse went out to assist RN#1 with transporting Patient #26 into the ED. RN#2 stated the patient did not want to come inside the ED and was resisting verbally and physically. RN#2 stated the patient fought with family and staff. RN#2 stated the patient appeared "manic" and "paranoid". RN #2 stated he saw the patient "head butt" RN#1 in the stomach, and later "slap" RN#1 in the face. RN#2 stated he saw the patient also kick the security officer in the chest area. RN#2 stated the patient was being restrained outside the ED by a male friend when the local police arrived. RN#2 stated the police told the patient to, "calm down and be seen, be arrested, or leave." RN#2 stated the patient and family/friends got in their car and left. RN#2 confirmed the patient was not provided any treatment and did not sign out AMA.

Interview with RN#1, by telephone, on January 24, 2013, at 3:20 p.m. revealed the nurse remembered the incident with Patient #26 on December 18, 2012. RN #1 stated, "I went out to help a patient out of a car and the patient's friend told me I had to get the patient out of the car, I told the friend, the patient had to come out of car on their own". RN#1 stated Patient #26 was, "beating on a man in the back seat of the car when I arrived, and the patient was saying over and over 'I don ' t want to be here, and why did you bring me here?" RN#1 also stated, "the patient was coaxed out of the car and was in the wheelchair and when I unlocked the brakes the patient rushed at me and tried to tackle me. The patient then ran to the north side of the hospital where the male friend caught her and they fought on the ground. I went and called security and...police department. We put her back in wheelchair and almost got inside the ED when patient jumped up and slapped me on the face. The patient's male friend restrained the patient again, and they struggled outside the ED." RN#1 stated, "I explained that the patient had a right to a medical examination, but that the patient would have to come into the ED. I told the patient and family that the patient could come into the ED and be seen, or they could take the patient home." RN#1 stated the patient was never told to go to another facility, and confirmed the patient was never examined by anyone at Hospital #1. RN#1 stated the ED physician was never aware the patient had presented to the ED. RN #1 confirmed the local police arrived and told the patient and family, "the patient could calm down and be seen, leave or be arrested, and they decided to leave." RN#1 stated the patient was not given any treatment and the patient was not asked to sign a leaving Against Medical Advise (AMA) release.

The hospital took the following actions:

Hospital #1 investigated this incident, and reported the findings of the incident to the Department of Health. Hospital #1's investigation found the ED staff did not follow the Hospital's policies and practices on December 18, 2012. Hospital #1 implemented a plan of correction which included:

1. Counseled staff involved in the incident on EMTALA requirements and management of violent patients.
2. Educated all ED and Labor/Delivery staff at the main hospital and all satellites on EMTALA requirements and management of violent patients. Security officers were also included in the training. All staff were also educated on the facility's Chain of Command Policy and the Violent Patient Policy.
3. An "Addendum" was added to the ED Log on 12/31/12 that included Patient #26's name.

Documentation of staff's attendance and completion of the training was provided to the Surveyor. ED staff interviewed during the compliant investigation confirmed the training had occurred and demonstrated knowledge of EMTALA requirements.

Interview with the Market Director of Quality, by telephone, confirmed facility compliance with the EMTALA requirements and other facility policies is being monitored by monthly chart and ED Log reviews, and of all incidents of patients leaving the ED without a Medical Screening Exam are investigated.

Based on review of a facility report, record review, policy review, and interviews, the facility failed to provide an appropriate transfer for one (#26) patient of twenty-six patients reviewed.

The findings included:

Review of a letter from the facility (Hospital #1), written to the Department of Health (DoH), dated December 21, 2012, revealed the facility, "wished to self-report...a potential violation of the Emergency Medical Treatment and Labor Act..."

Further review of the letter revealed Patient #26 was brought to Hospital #1's satellite facility's Emergency Department (ED) on December 18, 2012, at approximately 1:45 a.m., by family members and friends for complaint of possible drug ingestion and behaving "wild"

Further review of the letter revealed Patient #26, "...slapping her boyfriend...refusing to get out of the car...cursing...belligerent...fighting...head butted RN1 in the stomach...running...cursing RN1 and slapped RN1 in the face...kicked the security officer in the arm..."

Further review of the letter revealed Patient #26 was placed in a wheelchair and staff attempted to take the patient into the ED with the patient cursing and yelling at the family members. The letter revealed that before staff could transport the patient into the ED, the patient, "began cursing RN1 and slapped RN1 in the face...the patient's boyfriend restrained the patient...when the security officer tried to talk to the patient, the patient kicked the security officer in the arm."

Further review of the letter revealed, "RN1 had called the...Police Department for assistance...When the ...Police Officers arrived they asked RN1 what...wanted them to do with the patient ...RN1 indicated the ED was full and the patient was too violent to be brought into the ED." The letter also stated, "The Police Officers advised the patient and those that brought...to the ED that they would have to leave the property or the patient would be arrested".

Further review of the letter revealed, "The patient's friends placed the patient in the car and transported the patient to (Hospital #2) for treatment." The letter also stated, "The patient was admitted...with diagnosis of...altered mental status...hypokalemia...alcohol poisoning."

Further review of the letter revealed Hospital #1, "...failed to follow appropriate transfer procedures when the patient was transported to (hospital #2)".

Review of the ED log and ED records revealed no documentation of Patient #26 being examined or treated in the ED of Hospital #1. Further review of the ED records revealed no documentation of the patient being transferred from Hospital #1 to Hospital #2 on December 18, 2012.

Review of medical record from Hospital #2, revealed Patient #26 presented to the ED there on December 18, 2012, at 2:35 a.m. with complaint of Altered Mental Status. Review of the ED Triage Notes from Hospital #2, revealed, "pt (patient) was brought in by family ...was given unknown drugs, was taken to (Hospital #1) and they wouldn't take...so...came here. Pt is combative, altered. Pt immediately brought back to room...had to restrain pt for safety..."

Review of the physician's admitting history and physical from Hospital #2, dated December 18, 2012, revealed , "...took some unknown substances which rendered...confused and agitated ...had to be physically and chemically restrained...alcohol level 304 (toxic above 400)." Further review of the history and physical revealed, "admit to ICU (Intensive Care Unit)" with diagnosis of: Altered Mental Status, Alcohol Intoxication, Unknown Drug Consumption, Hypokalemia, and Dehydration".

Review of RN#1's written statement dated December 18, 2012, revealed the nurse went outside the ED on December 18, 2012, to assist a patient out of a car. Further review of RN #1's statement revealed, "...is slapping boyfriend and refuses to get out of car...I informed them I would not get...out of the vehicle and...would need to exit on ...own." The statement also revealed, "...charged out of the wheelchair and head butted me in the stomach...then took off running toward the north side of the hospital...boyfriend chased...tripped and fell...I noticed abrasions to left knee...attempted to approach...again placed...in the wheelchair...we got up ramp...almost to ER (Emergency Room) door when...began cursing and yelling at the two women who transported...here...then slapped me across the face...then was pulled out of wheelchair by...boyfriend onto the ground..." Further review of the statement revealed RN#1 called the local police department (PD) and when the police arrive they find, "the boyfriend has the pt in a headlock because...is still yelling and cussing at everyone and striking out at the security guard..." Further review of the written statement revealed the police, "told them to leave the property or ...would be arrested...I informed PD that...was too dangerous to bring back into the ER because we are completely full and the...is too violent..."

Review of facility policy titled, "EMTALA-Definitions and General Requirement" effective date September 1, 2012, revealed, "...provide for an appropriate transfer for the individual..."

Review of facility policy titled, "Emergency Department-Combative or Difficult to Manage Patient", reviewed date October 2011, revealed, "Patients who are difficult to manage, due to alcohol, drugs, or emotional problems, will be treated with care and dignity in a safe and secure environment. Staff are trained on how to care for and interact with combative or difficult patients ..."

Interview with Security Officer #1 (SO#1), on January 22, 2013, at 1:05 pm, in the Administration Conference Room, revealed the officer recalled the incident involving Patient #26 on December 18, 2012. Interview revealed SO#1 was called to the ED to meet RN #1 in the ED Lobby. SO#1 stated there was loud arguing outside the ED, and the officer went outside and saw RN #1 and Patient #26 "arguing". The security officer stated RN#1 and family tried to calm the patient, but the patient became irate and at one time a male friend or family member was physically restraining the patient. The security officer stated the patient kicked the officer in the right arm and slapped RN#1 in the face, and was "very out of control". The security officer stated the local police arrived and told the patient to leave. The security officer stated the patient left in a car with the family and/or friends. The security officer confirmed the patient never entered the ED.

Interview with the ED Director, on January 22, 2013, at 2:15 p.m., in the Administration Conference Room of Hospital #1's satellite facility, revealed hospital policy required Patient #26 be brought into the ED and provided a Medical Screening Examination, stabilizing treatment, and an appropriate transfer to another facility if needed. Further interview with the ED Director confirmed the ED staff did not follow facility policies, in regard to Patient #26's treatment on December 18, 2012.

Interview, on January 22, 2013, at 3:00 p.m. in the ED of Hospital #1's satellite facility, with MD#1, the physician working the ED of Hospital #1, when Patient #26 presented on December 18, 2012, revealed MD#1 did not see or examine the patient.

Interview with RN#2, by telephone, on January 24, 2013, at 11:15 a.m., revealed this nurse went out to assist RN#1 with transporting Patient #26 into the ED. RN#2 stated the patient did not want to come inside the ED and was resisting verbally and physically. RN#2 stated the patient fought with family and staff. RN#2 stated the patient appeared "manic" and "paranoid". RN #2 stated he saw the patient "head butt" RN#1 in the stomach, and later "slap" RN#1 in the face. RN#2 stated he saw the patient also kick the security officer in the chest area. RN#2 stated the patient was being restrained outside the ED by a male friend when the local police arrived. RN#2 stated the police told the patient to, "calm down and be seen, be arrested, or leave." RN#2 stated the patient and family/friends got in their car and left. RN#2 confirmed the patient was not transferred to another facility.

Interview with RN#1, by telephone, on January 24, 2013, at 3:20 p.m. revealed the nurse remembered the incident with Patient #26 on December 18, 2012. RN #1 stated, "I went out to help a patient out of a car and the patient's friend told me I had to get the patient out of the car, I told the friend, the patient had to come out of car on their own". RN#1 stated Patient #26 was, "beating on a man in the back seat of the car when I arrived, and the patient was saying over and over 'I don ' t want to be here, and why did you bring me here?" RN#1 also stated, "the patient was coaxed out of the car and was in the wheelchair and when I unlocked the brakes the patient rushed at me and tried to tackle me. The patient then ran to the north side of the hospital where the male friend caught her and they fought on the ground. I went and called security and ...police department. We put her back in wheelchair and almost got inside the ED when patient jumped up and slapped me on the face. The patient's male friend restrained the patient again, and they struggled outside the ED." RN#1 stated, "I explained that the patient had a right to a medical examination, but that the patient would have to come into the ED. I told the patient and family that the patient could come into the ED and be seen, or they could take the patient home." RN#1 stated the patient was never told to go to another facility, and confirmed the patient was never examined by anyone at Hospital #1. RN#1 stated the ED physician was never aware the patient had presented to the ED. RN #1 confirmed the local police arrived and told the patient and family, "the patient could calm down and be seen, leave or be arrested, and they decided to leave." RN#1 stated the patient was not transferred to another facility, and was not told to go to another facility.

The hospital took the following actions:

Hospital #1 investigated this incident, and reported the findings of the incident to the Department of Health. Hospital #1's investigation found the ED staff did not follow the Hospital's policies and practices on December 18, 2012. Hospital #1 implemented a plan of correction which included:

1. Counseled staff involved in the incident on EMTALA requirements and management of violent patients.
2. Educated all ED and Labor/Delivery staff at the main hospital and all satellites on EMTALA requirements and management of violent patients. Security officers were also included in the training. All staff were also educated on the facility's Chain of Command Policy and the Violent Patient Policy.
3. An "Addendum" was added to the ED Log on 12/31/12 that included Patient #26's name.

Documentation of staff's attendance and completion of the training was provided to the Surveyor. ED staff interviewed during the compliant investigation confirmed the training had occurred and demonstrated knowledge of EMTALA requirements.

Interview with the Market Director of Quality, by telephone, confirmed facility compliance with the EMTALA requirements and other facility policies is being monitored by monthly chart and ED Log reviews, and of all incidents of patients leaving the ED without a Medical Screening Exam are investigated.