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Based on review of facility policy, medical record review and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) for 1 patient (#4) who was admitted with a possible overdose and acute behaviors of 26 Emergency Department (ED) records reviewed; and failed to provide an appropriate transfer for 1 patient (#5) who was admitted with acute behaviors and required transfer to another acute care facility of 13 ED transfers reviewed.

The findings include:

Patient #4 was admitted to the ED on 12/8/2024 with a possible overdose of an unknown amount of non-steroidal anti-inflammatory medication. The patient became agitated and hostile and attempted to hit one of the Registered Nurses (RNs) with his fist. The patient exited the room prior triage vital signs being obtained related to the patient's acute behaviors. The local police department returned the patient to the ED where the ED physician spoke to the mother in the presence of the police officer. An appropriate MSE was not performed related to the patient's potential psychosis. The patient was at risk for potential self-harm and possible overdose. The patient left the ED with his mother.

Patient #5 presented to the ED with Psychosis, Auditory Hallucinations, Delusions, Suicide Ideation and Schizoaffective Disorder. The patient was transferred to an accepting facility, but an EMTALA form was not found in the medical record. In addition, risks and benefits of the transfer were not documented in the medical record.

Cross refer to A-2406 and A-2409.

Based on review of facility policy, medical record review, review of facility documentation, review of police report and interviews, the facility failed to provide an appropriate and ongoing Medical Screening Examination (MSE) for 1 patient (#4) who was admitted with a possible overdose and acute behaviors of 26 Emergency Department (ED) records reviewed.

The findings include:

Review of facility policy, "Emergency Screening/Stabilization/Transfer/250 Yard Rule and EMTALA," revised 3/2022, showed "...a Medical Screening Examination is the process required to reach a reasonable clinical confidence, the point as which it can be determined whether or not an Emergency Medical Condition exists...is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred..."

Medical record review of the ED nursing triage dated 12/8/2024 at 2:12 PM showed Patient #4 was brought to the ED by his mother and his 16-year-old-brother for treatment of a potential overdose of ibuprofen (non-steroidal anti-inflammatory medication).

Medical Record review of the ED nursing notes dated 12/8/2024 at 2:19 PM, showed two registered nurses (RNs) came to the lobby, after being called by registration regarding a possible overdose, to take the patient to treatment room #6. The mother and brother denied knowing the reason (s) for the overdose. The brother reported the patient had been passing out and couldn't speak. After the mother left the ED to move her car, the patient told the RNs he had taken 45 pills 45 minutes ago. When the brother raised his voice toward RN #2, Patient #4 stated "...don't [explicative] talk to him like that..." The 14-year-old patient began to yell and scream. He jumped up, tore the blood pressure cuff off and ripped his gown off and threw it across the room..." Patient #4 spit in the nurse's face, pinned her against the wall and raised his fist, but the mother grabbed his arm. The patient pushed his mother into the wall. As the ED physician was entering the room, the patient pushed the ED physician out of his way and proceeded to run down the hallway towards the ED lobby. Hospital security was paged, and the local police department was called.

Medical record review of the ED physician's record dated 12/8/2024 at 2:20 PM, showed "...14-year-old- male presented to ED with complaints of overdose and is questionable whether accidental or intentional overdose of ibuprofen. Patient was placed in room. Shortly after placed in room he became aggressive and violent towards the nursing staff. I did hear patient screaming loudly. I immediately went to the room and the door came open patient pushed by me running out of the building and security was alerted. Law enforcement was also alerted. I did speak with the patient's mother who stated that he is never attempted this before they recently moved to the area from [named city and state]. Patient is noted to have cuts on arms of what I could see on short visualization. Patient was cursing and violent. Patient left the ER [emergency room]..."

Medical record review showed triage vital signs and a MSE were not performed. The patient left the ED with his mother and the AMA form was not signed.

Review of the facility documentation (Incident Report) showed Security was called at 2:20 PM on 12/8/2024, for an assault in progress. The report showed patient #4 was running towards the security officer and pushed the security officer to the side. The patient was in a rage yelling he was going to hurt everyone and at this point it became a physical altercation between the patient and the security officer. For the safety of the people in the lobby the security officer let the patient exit outside. At 2:25 PM, the officer found the patient lying in the grass and not responding to his name when called. The officer called the admission department and asked them to update the police department of the security officer's location. The patient jumped up and screamed he "was going to kill us." The patient struck the security officer with a rock hitting her thigh. [local police department] arrived at 2:31 PM.

Review of the (local named police department) incident report showed officers responded to the ED on 12/8/2024 related to a "disturbance." They were informed the patient (#4) was being treated at the hospital for a drug overdose. They were advised Patient #4 had fled from the hospital on foot after his family caused a disturbance with the nurses. The police officers searched the area and found the patient walking westbound on a sidewalk where he was apprehended, placed in handcuffs and returned to the ED.

During an interview on 01/13/2025 at 1:32 PM, the ED Physician stated the patient's family reported the patient had taken ibuprofen. The Physician stated after one hour the patient should have had nausea and vomiting. He heard screaming and yelling. When he went to the Patient #4's room the patient was attempting to run out the door, and the door hit the ED physician. The patient left the ED, ran into the parking lot and laid on the ground. The patient picked up a large rock and threw it at the security guard. The physician informed the patient's mother he would check and examine the patient but only in the presence of the police.

During an interview on 1/13/2025 at 1:55 PM with Registered Nurse (RN) #1, she stated she was notified by registration the patient was "passing out." She and another registered nurse went to the ED lobby where she observed the patient's eyes were shut and spit running down his chin.

During a telephone interview on 1/14/2025 at 4:55 PM RN #2 stated her first assessment of the patient showed the patient leaning his head, holding spit in his mouth, and drooling. The patient appeared alert. The patient stated he had taken 45 pills about 45 minutes ago. The patient's brother stated Patient #4 was trying to kill himself. While removing his shirt and putting on a gown, she noticed scars up and down his arms. The mother stated "...he [the patient] has psych issues..." The mother became more aggressive, the patient hopped off the exam table, drew back his fist while he was spitting in her face and said he was going to kill her. The mother pulled back his arm and the two of them scuffled. The patient began to cry and scream as he ran out the door into the ED lobby and continue to scream, he was going to kill somebody.

During a telephone interview on 1/14/2025, at 6:06 PM with Security Officer #1, she stated while making rounds she was notified of an assault in progress and her help was needed. When she arrived in the lobby, the patient was standing in the lobby screaming "he was going to kill somebody." He pushed her aside and went out the double doors of the ED. She drove around the campus until she found him lying on his side in a grassy area. Security Officer #1 stated she thought the patient had passed out but when she leaned over him, he threw a large rock hitting her in the side of the leg. The patient started running again saying he was going to kill everyone in the ED. The [local police department] found the patient and brought him back to the ED EMS entrance.

Review of the medical record showed no further attempts were initiated to return the patient to the ED to continue his assessment, after the mother refused to have the police restrain her son. Interviews confirmed the mother left the hospital with her son.

Based on review of facility policy, medical record review and interviews, the facility failed to ensure risk and benefits related to a transfer were explained and failed to provide the Emergency Medical Treatment and Labor Act (EMTALA) transfer certification for 1 patient (#5) of 13 Emergency Department (ED) patients reviewed for a transfer.

The findings include:

Review of the facility policy, " Emergency Screening Stabilization/Transfer/250 Yard Rule and EMTALA," revised 3/2022, showed "...For transfer with physician certification. For a patient who has not been stabilized, a physician must have signed a certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual... from being transferred. This certification must contain a summary of the risks and benefits upon which it is based..."

Medical record review of Patient #5's ED nursing triage dated 12/20/2024 at 2:50 PM, showed the patient was admitted with Psychosis, Auditory Hallucinations, Delusions, and Suicidal Ideations without a plan. The patient stated she has been paranoid for 2 to 3 weeks and started a new medication for her psychiatric disorders. The patient's Emergency Severity Index (ESI) score was a 3 indicating urgent needs.

Medical record review of Patient #5's ED physician's documentation dated 12/20/2024 at 2:50 PM, showed the patient had previous history of Anxiety, Hallucinations, and Paranoia. The patient had experienced similar chronic episodes in the past where she had been seen two weeks prior for similar complaints. The patient's diagnosis included Schizoaffective Disorder, Bipolar Disorder with Psychotic Features, and Suicidal Ideations.

Medical record review of Patient #5's Disposition record dated 12/20/2024 showed a behavior health referral was sent to Facility B (inpatient behavioral health facility) and the referral was accepted.

Medical record review of Patient #5 ED visit on 12/20/2024 revealed there was no documentation regarding risks and benefits of the transfer to Facility B and there was no EMTALA transfer form in Patient #5's record.

During an interview on 1/14/2025 at 10:00 AM, in the Administrative Conference Room, the Quality Manager #1 and the ED Director confirmed there was no documentation of the risks and benefits of transfer in Patient #5's medical record on 12/20/2024. Further interview confirmed there was no EMTALA transfer form in patient #5's medical record for the ED visit on 12/20/2024.