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Based on a review of policy and procedures, facility surveillance video, police body camera video, medical records, and interviews with staff it was determined that (P#1) was not provided an appropriate medical screening examination (MSE) when he presented to the hospital's Emergency department, with Law Enforcement acting on his behalf and requested a mental evaluation. As this resulted in patient #1 not receiving an appropriate medical screening examination that was within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition existed.

Refer to findings in Tag A- 2406.

2405
Based on a review of policy and procedures, central log, facility Incident Report, facility surveillance video, police body camera video, and interviews with staff it was determined that the facility failed to maintain a central log when one (P#1) of 20 sampled patient was brought to the ED accompanied by law enforcement seeking medical assistance for a medical condition, and was not entered into the central log. P#1 presented to the facility's Emergency Department (ED) on 5/2/24 accompanied by law enforcement for a psychiatric evaluation.

Findings Included:

A review of the facility's policy titled "Transfer Activities in Accordance with EMTALA Requirements Policy," policy# 11101630, last revised 1/27/22, revealed the following definitions:
Record Keeping:
j. A central log on each individual who "comes to the Emergency Department" seeking assistance. Such log should include whether the patient."
" Refused treatment.
" Was refused treatment.
" Transferred to another facility.
" Was admitted and treated.
" Was stabilized and transferred.
" Was discharged.


A review of the facility's policy titled "Patients in Custody of Law Enforcement Agencies: Admission Hospital Safety and Dismissal (Guarded and Unguarded)," policy# 14644533, last revised 10/1/23, revealed the following: The policy revealed in part, 1. Admission/Registration ...access management will register the patient at that site."


A review of the facility's Central Log dated 11/1/23 through 5/14/24 failed to reveal that Patient (P) #1 was registered as a patient on 5/2/24 at 4:12 a.m.

A review of the facility's Incident Report dated 11/1/23 through 5/14/24 for the ED failed to reveal an entry related to P#1.

A review of the facility video recording time stamped 4/2/24 revealed: 11:47 a.m.: P#1 observed accompanied by a female police officer (PO JJ) and approached the ED registration desk. Despite Patient #1 being brought to the ED registration Desk by PO JJ, the facility failed to ensure the patient was entered in the central log as stated in their policy.
11:53 a.m. P#1 observed speaking to Patient Access Representative (PAR) EE.
12:29 p.m. PO JJ observed speaking with Patient Care Technician (PCT) DD. PO JJ remained at PAR EE's window.

At 4:12:19 a.m. a male officer (PO KK) was seen approaching PCT DD's window and appeared to speak with PCT DD while PO JJ remained with P#1 at PAR EE's window.

Further review revealed that at 4:12:33 a.m., PO KK moved to RN AA's window and began speaking with her.
At 4:12:47 a.m. PO JJ and P#1 observed moving closer to PCT DD's window. P#1 observed speaking to PCT DD. At 4:12:51 a.m., P#1 abruptly turned around and left the facility ED while both officers (PO JJ, and PO KK) remained at the registration window speaking to RN AA.

At 4:13:16 a.m., PO JJ was seen leaving the facility ED, while the PO KK remained speaking to RN AA until 4:13:30 a.m. when he was additionally observed leaving the ED area.

A review of officer body camera video (BCV) #1, timestamped 4:10:34 - 4:10:39, revealed that PO JJ approached PAR EE's window and said, "Hello, here for an eval, where do we go for that?"

Continued review of BCV #1, timestamped 4:10:40 - 4:11:23, revealed that PCT DD asked PO JJ, "What agency are y'all?" to which PO JJ replied, "Agency name. He requested to come here." P#1 interjected and asked, "Who? No, y'all brought me here. I didn't want to come to the hospital at first. I know you have to have a warrant to get people off to a property and y'all didn't give me no warrant. So, you know arrest them and take them in behind a locked door." PO JJ replied to P#1, "You're not under arrest though." P#1 responded, "But I'm saying a warrant is something that will put a person in a car." PO JJ explained, "No, a warrant is for an arrest." P#1 quickly interjected, "That's what I'm saying, you didn't give me a warrant. It was the first time you saw me on that property."

Continued review BCV #1, timestamped 4:11:24 - 4:11:36 PO JJ was seen moving closer to PCT DD's window during which time PAR EE asked P#1, "Are you checking in?" P#1 replied, "Naw, I don't wanna check in." PCT DD looked over to P#1 and said, "You're free to go." P#1 responded, "Okay.' and was seen walking out of the facility.

A review of BCV #2, timestamped 4:11:10 - 4:11:20, revealed that PO KK approached PCT DD and asked PCT DD, "Who do I need to speak to about this?" PCT DD then gestured with his finger, pointing, to RN AA.
Continued review of BCV #2, timestamped 4:11:21 - 4:11:45, revealed that PO KK approached RN AA and explained, "So, we found him lying down, face down over here by the old Sears building across from McDonald's." RN AA replied, "He said he didn't want to come here."

Continued review of BCV #2, timestamped 4:11:50 - 4:12:10 revealed that PO KK explained to RN AA, "Well, the reason we brought him over here is that he was saying that people were trying to rape him, like the police, you know, was raping him. Talking out of his mind." RN AA replied, "Did y'all assist him, or did y'all just decide to bring him here?" PO KK explained, "No, he said he wanted to come to Piedmont. We asked him if he wanted to go to (name of another hospital) and he specifically told us Piedmont and now he's changed his mind." RN AA replied, "Okay". PO KK was seen exiting the area.

During an interview on 5/14/24 at 4:25 p.m. in a board room with the Emergency Department Director (EDD) CC, EDD CC stated that she took the role of EDD CC on March 24. EDD CC said that she expects the check-in staff to enter all patients that enter the ED into the central log. She said that the former EDD did not require staff to enter patients under certain circumstances into the central log and that has created some confusion amongst the ED staff regarding the central log.

During an interview on 5/14/24 at 4:36 p.m. with Director of Patient Access (DPA) MM in a board room, DPA MM stated that her expectations of the patient access representatives (PAR) that work in the ED are to greet patients, enter the patient's information in the system, find out why they need to be seen and obtain consent signatures. She said everyone who comes into the ED to be evaluated should be evaluated. DPA MM added that she expects PAR to make every attempt possible to get the patients' information. When this surveyor asked about the facility's policy on the central log, DPA MM stated she did not know the facility's policy regarding record keeping in the central log.

A telephone interview was conducted on 5/14/24 at 9:15 p.m. with PAR EE. PAR EE stated that she remembered P#1 being brought in by a couple of AUPD (Augusta University Police Department) officers. She recalled asking P#1 to enter his social security number and P#1 responded by saying he did not want to check in. PAR EE said she did not have to enter P#1 into the central log because P#1 didn't want to provide his information. She said she would enter a patient as "Jane" or "John Doe" if the patient was unable to give their information.

During an interview on 5/15/24 at 10:12 a.m. with RN AA in a board room, RN AA stated that she recalled P#1 being brought into the ED by two officers. She added that if a patient does not give staff their information and they leave, nothing will be entered into the central log because staff would not know what information to add.

During an interview on 5/15/24 at 2:00 p.m. with CN LL in a board room, CN LL stated that she has been an ED Nurse for seven years and a relief ED Charge Nurse for one and a half years. CN LL said that she was working as the Charge Nurse in the ED on 5/2/24. CN LL did not recall being called or notified by staff that P#1 was brought in for an evaluation and left. She added that if she had been notified, she would have encouraged P#1 to go to a room with her to be evaluated by a provider. Additionally, she would have had PAR enter him as a "John Doe" in the central log if he had not provided his information. CN LL further added that she feels like there needs to be more employee education regarding EMTALA regulations and policies.

The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to maintain a central log on Patient #1 on 5/2/2024 who came to the emergency department seeking medical assistance, and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

Based on a review of policy and procedures, facility surveillance video, police body camera video, medical records, and interviews with staff it was determined that (P#1) was not provided an appropriate medical screening examination (MSE) when he presented to the hospital's Emergency department, with Law Enforcement acting on his behalf and requested a mental evaluation. As this resulted in patient #1 not receiving an appropriate medical screening examination that was within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition existed.

Findings Included:

A review of the facility's policy titled "Transfer Activities in Accordance with EMTALA Requirements Policy," policy# 11101630, last revised 1/27/22, revealed in part, " ...Definitions: Capacity was the ability of the receiving facility to accommodate an individual who had been referred for transfer from another facility and encompassed such things as numbers and availability of qualified staff, beds, and equipment and the hospital's past practices of accommodating additional patients in excess of its occupancy limits. Comes to the Emergency Department- with respect to an individual requesting examination or treatment for an emergency medical condition (EMC) that the individual was on the facility's property, at or within 250 yards of the main building, including parking decks/lots, sidewalks, and driveways.

Emergency Medical Condition -was a medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to psychic disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could be expected to result in either: a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or b. Serious impairment to bodily functions. c. Serious dysfunction of any bodily organ or part: or d. With respect to a pregnant woman who is having contractions: That there is adequate time to effect a safe transfer to another hospital before delivery; or that the transfer may pose a threat to the health or safety of the woman or her unborn child. Involuntary Status- applied equally to patients with psychiatric, drug, or alcohol-related conditions. Such patients who presented to the ED would receive a medical screening examination (MSE) and if they were found to have an EMC, they would receive stabilizing treatment within the capabilities and capacity of the facility. If their condition remained unstable an EMTALA appropriate transfer would be arranged for them. The appropriate involuntary transfer forms (1013;2013) for a general psychiatric referral or for a drug or alcohol referral, must be utilized and completed in addition to the hospital transfer forms. No consent to transfer the patient was required.


A review of the facility video recording time stamped 4/2/24 revealed: 11:47 a.m.: P#1 observed accompanied by a female police officer (PO JJ) and approached the ED registration desk.
11:53 a.m. P#1 observed speaking to Patient Access Representative (PAR) EE.
12:29 p.m. PO JJ observed speaking with Patient Care Technician (PCT) DD. PO JJ remained at PAR EE's window.

At 4:12:19 a.m. a male officer (PO KK) was seen approaching PCT DD's window and appeared to speak with PCT DD while PO JJ remained with P#1 at PAR EE's window.

Further review revealed that at 4:12:33 a.m., PO KK moved to RN AA's window and began speaking with her.
At 4:12:47 a.m. PO JJ and P#1 observed moving closer to PCT DD's window. P#1 observed speaking to PCT DD. At 4:12:51 a.m., P#1 abruptly turned around and left the facility ED while both officers (PO JJ, and PO KK) remained at the registration window speaking to RN AA.

A review of officer body camera video (BCV) #1, timestamped 4:10:34 - 4:10:39, revealed that PO JJ approached PAR EE's window and said, "Hello, here for an eval, where do we go for that?"

Continued review of BCV #1, timestamped 4:10:40 - 4:11:23, revealed that PCT DD asked PO JJ, "What agency are y'all?" to which PO JJ replied, "Agency name. He requested to come here." P#1 interjected and asked, "Who? No, y'all brought me here. I didn't want to come to the hospital at first. I know you have to have a warrant to get people off to a property and y'all didn't give me no warrant. So, you know arrest them and take them in behind a locked door." PO JJ replied to P#1, "You're not under arrest though." P#1 responded, "But I'm saying a warrant is something that will put a person in a car." PO JJ explained, "No, a warrant is for an arrest." P#1 quickly interjected, "That's what I'm saying, you didn't give me a warrant. It was the first time you saw me on that property."
Continued review BCV #1, timestamped 4:11:24 - 4:11:36 PO JJ was seen moving closer to PCT DD's window during which time PAR EE asked P#1, "Are you checking in?" P#1 replied, "Naw, I don't wanna check in." PCT DD looked over to P#1 and said, "You're free to go." P#1 responded, "Okay.' and was seen walking out of the facility.

The form titled, "Health Augusta Exam (MSE) Offer Report dated 5/2/2024 at 3:53 P.M. for patient #1 was reviewed. The questions asked on the form, "Was this individual offered medical treatment /Screening (MSE) Exam (examination), and "Was Medical/Treatment/Screening (MMSE) refused" and both boxes "yes was checked off. Further review revealed in part, "Specifics of Situation: ... Law enforcement not medical ...request Piedmont for Mental Eval (evaluation) once at Piedmont he said he did not want to be treated." Patient #1 reported to the hospital's emergency department by Law Enforcement, (acting on the patient's behalf) and requested a mental evaluation due the patient having altered mental status, and felt the patient needed be medically evaluated. The facility failed to ensure that their policy was followed as evidenced by failing to provide an appropriate medical screening examination was provided on 5/2/2024 when patient #1 presented to the hospital and a request was made by Law enforcement for a mental evaluation. The facility failed to ensure that Patient #1 was placed on an Involuntary Status due to the patient presenting to the hospital's ED with psychiatric condition, would receive a medical screening examination within the capabilities and capacity of the hospital as stated in the hospital's policy and procedure. On 5/21/24 patient #1 presenting to the ED with Law Enforcement (acting on Patient #1's behalf) requesting a mental evaluation because they found the patient experiencing altered mental status (a change in mental function), and no medical screening examination was provided by a Qualified Medical Personnel.

During a telephone interview on 5/14/24 at 3:15 p.m. with Police Captain (PC) BB, PC BB stated that he was made aware of the situation involving his offers and P#1. PC BB said that his officers conducted a building check on their property when they discovered P#1 lying face down in the grass. He said that the officers asked for P#1's name but were unable to verify it because their computer systems were down. PC BB stated that officers said that P#1 appeared to have an altered mental status, and they felt strongly that he needed to be medically evaluated. When officers spoke to P#1 about being screened, P#1 insisted on being brought to the facility. PC BB said that upon arrival at the facility registration area, P#1 told the patient care access representative that he did not want to be evaluated and declared that if he was not under arrest, he was leaving and then proceeded to walk out of the ED. Officers spoke to the ED nurse at registration and tried to explain that P#1 was not mentally stable. PC BB stated that an ED staff member said P#1 seemed of sound mind and could make his own decisions. He added that his officers filed an EMTALA form because that is what they are trained to do anytime they bring a patient to the facility needing a medical screening.

During an interview on 5/14/24 at 4:25 p.m. in a board room with the Emergency Department Director (EDD) CC, EDD CC stated that she took the role of EDD CC on March 24. She said that any patient that comes into the ED is supposed to receive an MSE and that if a patient refuses treatment the Charge Nurse should be notified, and they would have a qualified staff member try to speak with the patient and conduct an MSE. EDD CC said that neither a Patient Care Technician (PCT) nor a Registered Nurse (RN) are qualified to determine a patient's competency. She added that if a patient presents to the ED with an altered mental status a provider would need to declare the patient competent to make their own decisions.

During an interview on 5/14/24 at 4:36 p.m. with Director of Patient Access (DPA) MM in a board room, DPA MM stated that her expectations of the patient access representatives (PAR) that work in the ED are to greet patients, enter the patient's information in the system, find out why they need to be seen and obtain consent signatures. She said everyone who comes into the ED to be evaluated should be evaluated. DPA MM added that she expects PAR to make every attempt possible to get the patients' information.

A telephone interview was conducted on 5/14/24 at 9:15 p.m. with PAR EE. PAR EE stated that she has been a night shift PAR for the facility for seven years. PAR EE said that she remembered P#1 being brought in by a couple of PO's. She recalled asking P#1 to enter his social security number and P#1 responded by saying he did not want to check in. PAR EE added that she could recall either the PCT DD or RN AA going back and forth with the officers and that the officers told them that the patient requested to come to that facility. She further added that P#1 stated that he did not ask to go there and that if he was not under arrest he was leaving. PAR EE said that after P#1 made that statement he turned around and walked out. PAR EE stated that when a patient leaves the ED for any reason, she should let the charge nurse know. PAR EE could not recall if she let the Charge Nurse know that P#1 walked out. She added that it seemed to her that P#1 was the facility across the streets issue, and they just wanted to get rid of him, so they brought him to their facility. PAR EE further added that she receives annual EMTALA training

During an interview on 5/15/24 at 8:00 a.m. with Patient Care Technician (PCT) DD in a conference room, PCT DD stated that he has been a Certified Nurse's Assistant (CNA) for 14 years and a PCT for the facility for two years and four months. He added that his duties in the ED include taking patients from registration to a room, assisting patients from their vehicles, patient sitting, and assisting the nurses with anything they may need. PCT DD said the morning P#1 came in he was working at the check-in desk with PAR EE and RN AA. He recalled P#1 being accompanied into the ED by police officers. He additionally recalled hearing police officers (PO) say they found P#1 on an adjacent property, and then he heard P#1 say he did not want to be at the facility. PCT DD said that police officers should not have brought P#1 through that entrance. He added that patients accompanied by law enforcement are supposed to use a different entrance. He further added that he did not speak to the PO's or P#1 as the officers spoke to RN AA. PCT DD said that they have had three patients from another facility be brought in by PO's within one week, and P#1 was one of them. He said two were seen in the ED and one (P#1) was not seen. He added that staff are supposed to notify the Charge Nurse if a patient walks out and leaves. PCT DD recalled learning in EMTALA training that all patients seeking treatment in the ED should get an MSE at the bare minimum. He added that he receives EMTALA training annually.

During an interview on 5/15/24 at 10:12 a.m. with RN AA in a board room, RN AA stated that she recalled P#1 being brought into the ED by two PO's. She recalled hearing PO KK say that they found P#1 asleep on their property. She said P#1 told the staff at the window that he did not ask to come to the facility. RN AA said protocol, when a patient is brought in by law enforcement, is for PAR to get the patient's information, such as name and birthdate, while police give the RN a report on the patient. She added that if a patient is in custody, then the patient has no choice but to stay and P#1 told the staff that he was not in custody. Additionally, she said that P#1 did not appear to be in any distress, in her opinion, but that she did not speak to him directly. She explained that she is expected to call the charge nurse if a patient walks out of the ED without being evaluated. RN AA could not remember if she called the charge nurse when P#1 left the facility. RN AA said that per EMTALA regulations, the facility cannot refuse treatment to anyone who comes through the ED door. RN AA stated that she receives annual EMTALA training.

During an interview on 5/15/24 at 2:00 p.m. with CN LL in a board room, CN LL stated that she has been an ED Nurse for seven years and a relief ED Charge Nurse for one and a half years. CN LL said that she was working as the Charge Nurse in the ED on 5/2/24. She said she frequently works at the check-in desk triaging patients as they come into the ED. CN LL stated that when a patient with an altered mental status comes into the ED she has them assessed first by an ED provider and if the patient is unable to provide their information, she enters them into the central log as "Jane" or "John Doe" regardless of what their disposition ends up being. CN LL added that if a patient wants to leave or tries to leave the facility the Charge Nurse should be notified immediately so they can speak to the patient and try to encourage the patient to stay and discuss the risks and benefits of leaving. CN LL did not recall being called or notified that P#1 was brought in for an evaluation and left. She added that if she had been notified, she would have encouraged P#1 to go to a room with her to be evaluated by a provider. CN LL further added that she feels like there needs to be more employee education regarding EMTALA regulations and policies. CN LL said she receives annual EMTALA training.