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Based on policy review, medical record review, and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital failed to ensure a timely medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 20 sampled patients who presented to the DED (Patient #1).

~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406

Based on policy and procedure review, medical record review and staff interviews, the hospital failed to ensure a medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) to determine whether or not an emergency medical condition existed for 1 of 20 sampled patients who presented to the DED (Patient #1).

The findings included:

Review of the policy "EMTALA-Medical Screening and Treatment of Emergency Medical Conditions" effective 11/10/2003 revealed "...Procedures ...3. Medical Screening Examination ...The Hospital must provide for an appropriate Medical Screening Examination conducted by a physician or other Qualified Medical Professional ...to determine whether or not an Emergency Medical Condition exists ..."

Review of the policy "Against Medical Advice, Patients Leaving the Hospital" effective 03/2021 revealed, "...PURPOSE ...Patients leaving against medical advise (AMA) are defined as those patients who leave the Emergency Department after being examined by the ED physician; patients who leave the unit prior to being discharged by the physician; or where the risks of leaving prior to completion of evaluation and treatment has been explained by the ED physician or hospitalist. POLICY: 1. Patients who leave the hospital without a discharge order are considered to have left against medical advice (AMA). 2. When a patient expresses intent to leave the hospital AMA, the attending physician shall be notified by the nursing supervisor, charge nurse, the patient's primary nurse, and/or unit director. 3. The provider shall communicate the risks of leaving against medical advice to the patient and/or family and shall document this interaction in the medical record. If the provider is unable to see the patient prior to their departure, the nurse should make every attempt to obtain the patient's signature on the AMA form and shall inform the patient of the risks of leaving AMA. ..."

Dedicated Emergency Department (DED) medical record review on 07/22/2021, revealed Patient #1 was a 50-year-old female who arrived to the DED on 07/15/2021 at 1014. Medical record review revealed Patient #1 was triaged at 1034. Review of the Triage Note revealed "...Hysterectomy March, stabbing pain in back, Dx (diagnosed) with UTI (Urinary Tract Infection) taking antibiotics but not getting any better..." Triage review revealed vital signs were: temperature 98.1, pulse 78, respirations 18, blood pressure 121/76, and SpO2 (pulse oximetry) of 96% on room air. Further review revealed a pain score of 8 in the lower abdomen was obtained and Patient #1 was assigned an acuity level of 3. At 1038, per review, Patient #1 was put in an ED room. Review of "Orders" revealed an order for a urinalysis at 1109, which was later canceled with the reason "Patient Discharged." Review of a document titled "ED Note Nursing", at 1114, revealed "Pt (Patient) husband presents to nursing desk requesting nursing assistance. Husband states 'My wife needs a nurse in here.' This RN (registered nurse) responded 'Is there something specific we can bring her?' Husband states 'Yeah, some pain medication. She's been back here and hasn't seen anyone. This is a hospital, but no one has seen her and she's in a lot of pain.' As husband walked away he continued to speak, but with back turned, unable to hear what he was saying.' Momentarily husband heard raising voice, coming back to nurses (sic) station. He then demanded this RN's first name, last name, and employee ID number.' This RN provided first name and explained for privacy, I could not give my last name and for security reasons, I could not give employee ID number. Pt and husband began yelling profanity at this RN stating, 'I want your information, you were cussing at me...' At this point pt and husband beginning to become increasingly agitated. RN requested they step in the lobby, and house supervisor will be notified. (Name) RN contacted to speak with patient." Medical record review revealed documentation Patient #1 discharged from the DED at 1110. Review of an "Admit-Discharge-Transfer Forms" Note by RN #17 at 1307 revealed "...ED Disposition: Left prior to MSE (Medical Screening Exam) Reason for Leaving: Wait too long ED Eloped Comment: Husband and Pt came out started yelling at this RN and other RN's that we were not getting to her fast enough. 'This is an Emergency room I should be seen.' Pt and family were both not able to be talked down and left..." Medical record review failed to reveal documentation the nursing staff explained the risks of leaving, that the physician was notified, that Patient #1 signed or refused to sign the AMA (against medical advice) Release form, or that the staff explained the patient's right to return or receive follow-up care per hospital policy. Review failed to reveal evidence that Patient #1 received an MSE prior to leaving the DED.

Interview on 07/21/2021 at 1440 with RN #17 revealed after triage was completed, RN #17 escorted Patient #1 to an ED room and gave her a specimen cup for a urine sample. Interview revealed prior to RN #17 returning to Patient #1, the patient's husband approached the nurses' station and spoke with RN #18. Interview revealed Patient #1 and her husband informed staff in the nurses' station the patient was leaving the ED. Interview revealed RN #17 was with another patient and did not have time to talk to Patient #1 about the risks of leaving prior to receiving a medical screening exam. Interview revealed an ED provider had not been assigned to assume care of Patient #1 at the time she left the ED. Interview revealed Patient #1 did not receive an MSE prior to leaving the ED.

Telephone interview on 07/21/2021 at 1618 with RN #18 revealed she was working at the desk in the nurses' station when Patient #1's husband approached the desk. Interview revealed Patient #1's husband reported the patient was in pain, that she needed pain medication and she had not been seen by anyone. Interview revealed RN #18 informed the patient's husband she would notify the primary nurse. Interview revealed Patient #1 and her husband returned to the nurses' station. Interview revealed Patient #1 stated she was leaving the ED. Interview revealed RN #18 informed Patient #1 if she wanted to leave the ED, the staff "could not make her stay." Interview revealed the staff offered to have Patient #1 and her husband wait for the House Supervisor in the lobby of the ED as a "de-escalation technique." Interview revealed the AMA form was offered to patients who report they are leaving the ED against medical advice after being seen by a provider.

Telephone interview on 7/22/2021 at 1554 with the House Supervisor (RN #19) revealed she was called to the ED on 07/15/2021 for a patient complaint. Interview revealed when she arrived to the ED, Patient #1 and her husband were waiting in the lobby. Interview revealed Patient #1 and her husband were irate that they had been in the ED and things were not happening fast enough. Interview revealed Patient #8 began to cuss at RN #19. Interview revealed RN #19 did not discuss the risks of Patient #1 leaving the ED without being seen by a provider or leaving against medical advice. Interview revealed the primary nurse usually advised the patient of the risks of leaving AMA or leaving without being seen by a provider. Interview revealed RN #19 was not aware if the primary nurse (RN #17) advised Patient #1 of the risks of leaving AMA or if she asked the patient to sign an AMA form.

Interview on 07/23/2021 at 1247 with the ED Director revealed when a patient threatens to leave the ED against medical advice, the provider will discuss with the patient the risks of leaving versus benefits of staying for examination and treatment. Interview revealed if the provider does not have the opportunity, the expectation would be the nurse would talk to the patient about risks and benefits of leaving AMA and try to get the patient to sign the AMA form. Interview revealed, if the patient refuses to sign the AMA form, the expectation would be for the nurse to document the refusal in the patient's electronic medical record.

An interview was requested with the admitting medical doctor of record who was unavailable for interview.

In summary, Patient #1 arrived at the ED at 1014 and left at 1110 (54 minutes) later. There was no documentation Patient #1 received a medical screening exam prior to leaving the ED. There was no documentation the ED staff educated Patient #1 on the risks of leaving the ED prior to receiving a medical screening exam.