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Based on staff interview, medical record review, review of the Medical Staff Bylaws and Medical Staff Rules and Regulations, Governing Body Bylaws, and policy and procedure review, the facility failed to provide a Medical Screening Exam to determine if a an emergent medical condition exists or take all reasonable steps to have the individual or legally responsible person sign a Leaving Against Medical Advise/Refusal of Care (AMA) form and provide education on the risk and complications if not treated for one (1) of 20 medical records reviewed, Patient #1

Findings Include:

Review of ED medical record for Patient #1 on 09/02/2025 reveals patient arrived at 4:22 p.m. was triaged at acuity level three (3) and left the facility before a medical examination was performed, 11 hours later 09/03/2025 at 3:26 a.m. The medical record reveals the patient had a triage reassessment approximately every three (3) hours based on the facility's policy and remained at level three (3) acuity. The medical record does not contain documentation of a Medical Screening Exam (MSE) or documentation of an Against Medical Advise (AMA) form with documentation of risks for leaving without medical approval.

Review of the facility's Medical Staff Bylaws last review dated 03/26/2024, reveals " ...MEDICAL STAFF RULES & REGULATIONS ...EMTALA ...providers are required to comply with their obligations under the Emergency Medical Treatment and Labor Act and its corresponding regulations ...to assure ...all patients presenting to the Hospital's emergency department receive an appropriate medical screening examination ...to determine whether or not an emergency medical condition exists, as required by law ...Transfers must be conducted in accordance with the hospital's admission and transfer policies ...".

Review of the Governing Body Bylaws dated 07/18/2025, reveals " ...EMERGENCY ...means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in ...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 ...serious impairment to bodily functions ...serious dysfunction of any bodily organ or part ...".

Review of the facility's Patient Rights and Responsibilities dated 12/11/2023, reveal " ...respect the rights of patients throughout their course of treatment ...Individuals shall be accorded impartial access to treatment that is available and medically indicated ...within the capabilities of the institution and its resources ...include consideration of the psychosocial, spiritual, and cultural variables that influence the patient's perception of illness ...The patient will be informed of the existence of medically significant alternatives for care or treatment ...Discharge Care ...The patient and/or the family has the right to be informed by the physician responsible for care ...".

Review of the facility's Adult Emergency Department (AED) Discharge Policy dated 03/20/2024, reveals " ...The discharge of patients from the Emergency Department is the responsibility of the emergency physician or the primary physician who is responsible for the patient's care ...Vital signs should be stable ...pain assessment ...Recommendations for follow-up ...General aftercare instructions ...Patients leaving against medical advice (AMA) should be aware of the following before discharge ...diagnosis/condition ...Possible complications if not treated as advised ...option of being transferred ...have an unconditional invitation back to the Emergency Department ...".

Review of the facility's Emergency Medical Treatment and Active Labor Act (EMTALA) policy dated 07/08/2025, reveals " ...a Medical Screening Examination ...to determine if the individual has an Emergency Medical Condition ...if it is determined that the individual has an Emergency Medical Condition, to provide the individual with such further medical examination and treatment a required to stabilize the Emergency Medical Condition ...or to arrange for transfer ...a medical condition manifesting itself by acute symptoms of sufficient severity ... absence of immediate medical attention could reasonably be expected to result ...in placing the health of the individual ...in serious jeopardy... Serious impairment of bodily functions ...serious dysfunction of any bodily organ or part ... Medical Screening Examination determines within reasonable medical probability whether or not an Emergency Medical Condition exists ...The Medical Screening Examination is an ongoing process ...after an initial Medical Screening Examination, a physician or Qualifies Medical Person determines that the individual requires the services of an on-call physician, the on-call physician is contacted ...all reasonable steps to have the individual or legally responsible person sign a Leaving Against Medical Advise/Refusal of Care Form ...The medical record contains a description of the examination, treatment, or both ...that was proposed but refused by or on behalf of the individual ...".

An interview with Physician (MD) #1 on 10/09/2025 at 3:22 p.m. confirmed that when a patient comes to the Emergency Department (ED) the patient receives an electrocardiogram (EKG) in triage, the EKG is then read by a provider, and the reading of an EKG is the start of the Medical Screening Exam. MD #1 also confirmed that a provider who was approved to perform a medical screening exam (MSE) did not assess Patient #1 or Patient #2 during their ED visit on 09/02/2025.

During exit conference on 10/09/2025 at 5:30 p.m. with Vice Chair for Clinical Affairs MD, Chief Nursing Executive, Director of Risk Management and Patient Safety, Chief Executive Officer, Chief Nursing Officer of Adult Hospitals, Chief Operations Officer, and Chief Medical Officer (CMO) survey findings were discussed, and no further documentation was submitted for review.

Cross Refer to A-2406/489.24 for additional information.

Based on staff interview, medical record review, review of the Medical Staff Bylaws and Medical Staff Rules and Regulations, Governing Body Bylaws, and policy and procedure review, the facility failed to provide a Medical Screening Exam to determine if an emergency medical condition exists for 11 hours for Patient #1 resulting in the patients leaving the facility before a medical screening exam (MSE) was performed for one (1) of 20 medical records reviewed, Patient #1

Findings Include:

Review of ED medical record for Patient #1 on 09/02/2025 reveals patient arrived at 4:22 p.m. as a transfer from Hospital #2 for the management of malignant pleural effusion, hyperbilirubinemia, and complications of metastatic melanoma, had a diagnosis of metastatic liver, bony metastases and lung cancer, Patient #1 is enrolled in a clinical trial in another state and recently underwent paracentesis and thoracentesis one (1) week ago. Triage was started at 4:29 p.m. At 3:05 a.m. urethral catheter removed and access to subclavian port removed at 3:26 a.m. The patient and family requested to leave without seeing doctor, staff assisted patient in getting cleaned up and personal clothes on and assisted patient to their car per request. The medical record does not contain documentation of a Medical Screening Exam (MSE) or documentation of an Against Medical Advise (AMA) form with documentation of risks for leaving without medical approval documented. Patient #1 was discharged 09/03/2025 at 3:26 a.m.

Review of Patient #1's medical record from Hospital #3 reveals, family member took patient to Hospital #3 emergency department on 09/04/2025 at 12:12 p.m. After assessment Patient #1 was admitted to Hospital #2 with a history of widely metastatic choroid melanoma, hypertension, type two (2) diabetes, and advanced liver disease was admitted with management of acute kidney injury, worsening shortness of breath. Paracentesis was performed on 09/04/2025 in emergency department. During admission Patient #1 developed disseminated intravascular coagulation (DIC) (a serious disorder where blood clots form throughout the bloodstream, leading to organ damage and bleeding) requiring transfusions and had acute liver failure with hepatic coma. Patient had moderate malnutrition and remained critically ill with persistent anemia, worsening coagulopathy and progressive multi-organ dysfunction.

Review of the facility's Medical Staff Bylaws last review dated 03/26/2024, reveals " ...MEDICAL STAFF RULES & REGULATIONS ...EMTALA ...providers are required to comply with their obligations under the Emergency Medical Treatment and Labor Act and its corresponding regulations ...to assure ...all patients presenting to the Hospital's emergency department receive an appropriate medical screening examination ...to determine whether or not an emergency medical condition exists, as required by law ...Transfers must be conducted in accordance with the hospital's admission and transfer policies ...".

Review of the Governing Body Bylaws dated 07/18/2025, reveals " ...EMERGENCY ...means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in ...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 ...serious impairment to bodily functions ...serious dysfunction of any bodily organ or part ...".

Review of the facility's Emergency Medical Treatment and Active Labor Act (EMTALA) policy dated 07/08/2025, reveals " ...a Medical Screening Examination ...to determine if the individual has an Emergency Medical Condition ...if it is determined that the individual has an Emergency Medical Condition, to provide the individual with such further medical examination and treatment a required to stabilize the Emergency Medical Condition ...or to arrange for transfer ...a medical condition manifesting itself by acute symptoms of sufficient severity ... absence of immediate medical attention could reasonably be expected to result ...in placing the health of the individual ...in serious jeopardy... Serious impairment of bodily functions ...serious dysfunction of any bodily organ or part ... Medical Screening Examination determines within reasonable medical probability whether or not an Emergency Medical Condition exists ...The Medical Screening Examination is an ongoing process ...after an initial Medical Screening Examination, a physician or Qualifies Medical Person determines that the individual requires the services of an on-call physician, the on-call physician is contacted ...all reasonable steps to have the individual or legally responsible person sign a Leaving Against Medical Advise/Refusal of Care Form ...The medical record contains a description of the examination, treatment, or both ...that was proposed but refused by or on behalf of the individual ...".

An interview with Physician (MD) #1 on 10/09/2025 at 3:22 p.m. confirmed that when a patient comes to the Emergency Department (ED) the patient receives an (EKG) in triage, the EKG is then read by a provider, and the reading of an EKG is the start of the Medical Screening Exam. MD #1 also confirmed that a provider who was approved to perform an MSE did not assess Patient #1 or Patient #2 during their ED visit on 09/02/2025.

During exit conference on 10/09/2025 at 5:30 p.m. with Vice Chair for Clinical Affairs MD, Chief Nursing Executive, Director of Risk Management and Patient Safety, Chief Executive Officer, Chief Nursing Officer of Adult Hospitals, Chief Operations Officer, and Chief Medical Officer (CMO) survey findings were discussed, and no further documentation was submitted for review.

Cross Refer to A-2400/489.20 (l) for additional information.