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Based on review of policies, medical record review, and staff interviews, the Critical Access Hospital ' s administrative staff failed to ensure the Emergency Department (ED) staff at the Hospital provided, with the hospital ' s capabilities, an appropriate medical screening examination (MSE) to 1 of 20 emergency patients reviewed from 8/1/23 to 2/1/23 (Patient #18). Failure to provide an appropriate MSE to all patients presenting to the ED seeking medical care placed them at risk for undetected emergency medical conditions.

Failure to provide the appropriate MSE and stabilizing treatment per hospital policy placed patients at risk for deterioration of health and potential risk of death.

Findings include:



Hospital Capabilities:

1. The CAH hospital ED was a level 4 Trauma Center staffed by physicians 24/7. X-ray and Lab were available after hours on call. The ED had the capability to care for the OB patient with Fetal Monitoring and Doppler Fetal heart tones as well as on-call ultrasound. OB nurses were available to float to the ED from the OB unit if needed. The CAH hospital ED had no specialty on-call staff, but had the availability to do phone consultations and patients were transferred from the facility if a higher level of care was needed. Example: Neurology, Cardiology, Substance abuse, Psychiatric care.

2. Review of patient #18's Medical Record revealed:

a. Patient #18, presented to the Emergency Department (ED) on 1/14/24 at 7:55 PM via ambulance. Patient was mandated to the Residential Care Facility (RCF) by a County Court. Patient arrived at the ED unaccompanied by staff from the RCF. Patient #18 complained of facial and ankle pain after a confrontation with one or two fellow residents. Patient reported being punched on the side of the head leaving a contusion to the right lateral frontal cheekbone. Patient also reported being kicked in the leg and ankle. Patient denied strikes to the abdomen, and denied abdominal or chest pain.General palpation of the abdomen was performed by a physician. No doppler heartbeat check performed, no ultrasound ordered, no fetal heart tone monitoring, no labs drawn to further assess the health status of the unborn child and the health and safety of the mother.

b. On 1/14/2024 at 7:55 PM Staff D ED Registered Nurse, documented ED notes: Patient #18 arrived per Ambulance with complaint of "bump on my head" from a fight and being struck by a hand during an altercation with a male resident. Patient reports that they were pushed against a cabinet, choked and punched several times in the right cheek at least 4 times and kicked in the leg, there is an abrasion on the ankle. Patient stated they were"12 weeks pregnant", and concerned about the baby. Triage Vital Signs: Blood Pressure (BP) 124/72, Respiratory Rate (RR) 18 breaths per min, Heart Rate (HR) 97 beats per minute, Oxygen saturation (O2 Sat) 98% on room air, Temperature 98.4 degrees Fahrenheit. Patient denied any substance abuse or alcohol use. Patient had a Broset Violence and Columbia suicide screening scoring zero on both.

c. On 1/14/2024 at 8:07 PM Staff A ED physician, documented, Patient #18, arrived by ambulance and law enforcement. Law enforcement did not stay after rooming the patient. Patient was on a mandated short stay at RCF. The patient may have instigated a confrontation with one or two fellow residents at the RCF. One of the residents punched the patient in the side of the head leaving a contusion on their right lateral and frontal cheekbone also on the left anterior ankle. Patient was approximately 12 weeks pregnant, was struck in the thigh and left side, but not struck in the abdomen, the patient was not having abdominal or chest pain. Physical exam revealed no acute distress, normal weight, normal systems, abdomen soft, non-tender per palpation, bowel sounds present, pupils equal and reactive to light. Abrasion/contusion to anterior ankle and cheek. Medical decision making was straightforward, injuries were minor, no imaging or lab were ordered. Psychiatric examination revealed a normal mood. Mental status alert and oriented to person, place and time. Neurological exam revealed no focal deficit present.

3. During an interview on 8/12/24 at 2:45 PM Staff A ED physician, recalled Patient #18 came to the ED by ambulance with chief complaint of being assaulted, with injuries sustained to the face after being struck by a male resident at the RCF, but not struck in the abdomen. Patient appeared upset and by the time the patient left the ED they were in a more settled mood. Staff A, recalled patient stated they were 12 weeks pregnant, Patient denied any abdominal or chest pain when asked. Patient complained of pain to face and ankle, denied abdominal pain or chest pain. Situation did not warrant any additional lab or x-rays based on presenting symptoms and medical evaluation. Abdomen was soft and nontender to palpation. Staff A ED Physician reported they saw the patient in room 4 and did an examination. Staff informed me that the patient had left the ED after I examined her and could not be located. Patient was returned to the ED a short time later by law enforcement and refused to be reexamined and signed out AMA. Due to the minor injuries "I did not feel pregnancy testing or listening for fetal heart tones was warranted in this situation." The hospital had the capabilities to screen the OB patient for fetal heart tones and ultrasound; ED Physician A expressed that additional tests were not warranted.

4. During an interview 8/15/24 at 2:30 PM with Staff C ED Registered Nurse/Manager, recalled, Patient #18 had no indications that they were suicidal and was in the ED for assault. Columbia suicide and Brofet screening was negative for violence or suicide. Per Mental Health Policy 1:1 sitter was not indicated per violent and suicide score. "There was a mandate for the RCF where the patient was residing, not for the hospital." Staff C stated "The RCF had the responsibility to notify us if the patient had a mandate and any concerns of mental health issues when sending them to the ED." ED had the capability of providing 1:1 sitter at any time. Would call staff down from the floor or ambulance personnel to sit with the patient. "Do what we can within our capabilities to have a sitter for the patient. Even if that means calling in additional staff to cover the 1:1 sitter."

Based on review of policies, medical record review, and staff interviews, the Critical Access Hospital ' s administrative staff failed to ensure the Emergency Department (ED) staff at the Hospital provided, with the hospital ' s capabilities, an appropriate medical screening examination (MSE) to 1 of 20 emergency patients reviewed from 8/1/23 to 2/1/23 (Patient #18).

Failure to provide an appropriate MSE to all patients presenting to the ED seeking medical care placed them at risk for undetected emergency medical conditions.


Findings:

1. Review of Policy, "Mental Health Patient Care and Observation," last revised 7/24, revealed in part:
"...Patients who enter the ED with a mental health concern are roomed in room 4 and equipment is removed for patient safety. If a patient is violent or has aggressive behavior then they should be placed under ordered direct 1:1 supervision by hospital staff, until the medical provider has deemed the patient not at risk to harm themselves or others ..."

2. Review of Policy, "EMTALA Medical Screening exam," last revised 10/4/23, revealed in part:
"... Section 1 of "Comes to the emergency department: has presented at a hospitals ' dedicated emergency department, as defined in this section and requests examination or treatment for a medical condition ..."

3. Review of Policy, "Obstetrical Screening exam," last revised 7/24, revealed in part:

a. "...Definition section, Emergency Medical condition or "EMC" means a medical condition that manifests itself by acute symptoms of enough severity such that the absence of medical attention could reasonably be expected to result in one of the following: 1) placing the health of the individual (with respects to the pregnancy woman, the health of the unborn child) in serious jeopardy ..."

b. "... Medical screening examination or "MSE" is the process required to reach with reasonable clinical confidence, the point at which can be determined whether a medical emergency does or does not exist. A MSE is an ongoing process. Depending on the patient's condition, a MSE may involve: 1) a simple press such as a brief history of a medical exam; 2) a complex process such as a history and physical examination, followed by ancillary studies and procedures 3) anything in between ..."

c "... regardless of gestational age, when trauma and/or emergency medical conditions are present in the pregnant patient, the patient will be assessed in the emergency department first, and the location of further assessment and treatment will be at the discretion of the emergency department provider. All patients presenting for evaluation will receive at a minimum the standard obstetric evaluation as indicated by the obstetrics evaluation form. A qualified evaluator will perform this. The results of any scoring indicate that a physical exam is required, or upon the request of the nurse evaluator, the patient must be seen by a physician without waiting for further interval scoring. The patient's attending physician or the on-call physician will examine the patient for the purposes of completing the medical screening exam. The manager is responsible for ensuring that their staff are complying with this policy/ procedure ..."

4. Review of Patient #18's medical record revealed the following:

a. Patient #18, presented to the Emergency Department (ED) on 1/14/24 at 7:55 PM via ambulance.

b. On 1/14/2024 at 7:55 PM Staff D ED Registered Nurse, documented the following ED notes: Patient #18 arrived per Ambulance with complaint of "bump on my head" from a fight and being struck by a hand during an altercation with a male resident. Patient reported that they were pushed against a cabinet, choked and punched several times in the right cheek at least 4 times and kicked in the leg, there was an abrasion on the ankle. Patient stated they were"12 weeks pregnant", and concerned about the baby. Triage Vital Signs: Blood Pressure (BP) 124/72, Respiratory Rate (RR) 18 breaths per min, Heart Rate (HR) 97 beats per minute, Oxygen saturation (O2 Sat) 98% on room air, Temperature 98.4 degrees Fahrenheit. Patient denied any substance abuse or alcohol use. Patient had a Broset Violence and Columbia suicide screening scoring zero on both (indicating no concern with suicidal ideation or a concern with violent behavior).

c. On 1/14/2024 at 8:07 PM Staff A ED Physician, documented, Patient #18, arrived by ambulance and law enforcement. Law enforcement did not stay after rooming the patient. Patient was on a mandated short stay at Residential Care Facility (RCF). The patient may have instigated a confrontation with one or two fellow residents at the facility. One of the residents punched the patient in the side of the head leaving a contusion on their right lateral and frontal cheekbone also on the left anterior ankle. Patient was approximately 12 weeks pregnant, was struck in the thigh and left side, but not struck in the abdomen, the patient was not having abdominal or chest pain. Physical exam revealed no acute distress, normal weight, normal systems, abdomen soft, non-tender per palpation, bowel sounds present, pupils equal and reactive to light. Abrasion/contusion to anterior ankle and cheek. Medical decision making was straightforward, injuries were minor, no imaging or lab were ordered. Psychiatric examination revealed a normal mood. Mental status alert and oriented to person, place and time. Neurological exam revealed no focal deficit present.

5. During an interview on 8/12/24 at 2:45 PM Staff A ED Physician, recalled Patient #18 came to the ED by ambulance with chief complaint of being assaulted, with injuries sustained to the face after being struck by a male resident at the RCF, but not struck in the abdomen. Patient appeared upset and by the time the patient left the ED they were in a more settled mood. Staff A, recalled patient stated they were 12 weeks pregnant. Patient denied any abdominal or chest pain when asked. Patient complained of pain to face and ankle, denied abdominal pain or chest pain. Situation did not warrant any additional lab or x-rays based on presenting symptoms and medical evaluation. Abdomen was soft and nontender to palpation. Staff A ED Physician reported they saw the patient in room 4 and did an examination. "Staff informed me that the patient had left the ED after I examined her and could not be located. Patient was returned to the ED a short time later by law enforcement and refused to be reexamined and signed out AMA." Due to the minor injuries "I did not feel pregnancy testing or listening for fetal heart tones was warranted in this situation."

6. During an interview on 8/13/24 @4:47 PM Staff D ED Registered nurse, recalled Patient #18 was seen in the ED after an assault at the RCF by another resident. Patient was struck about the face and shoved into a cabinet per patient report. Patient was seen for facial contusion and ankle abrasion. Did disclose that they were 12 weeks pregnant. Staff D ED RN explained "Doppler fetal heart tones are generally completed at 20 weeks, anything earlier than that you may not get anything" and "up to the provider discretion to complete the screening." Staff D ED RN reported the patient arrived by ambulance unaccompanied by staff from the RCF. Patient was on a court mandate to the RCF. Hospital did not receive any type of report from the RCF. Staff ED RN stated, "(Patient) was triaged and examined by the physician in the ED, and shortly after the exam, left the ED unwitnessed as I was in another room with a patient." RCF and Law enforcement (LE) were notified of the missing patient after searching the ED and hospital. Staff ED RN stated, "When I called the RCF to report the elopement they stated that the patient does this often." Patient #18 returned a short time later accompanied by LE with an orange soda in hand acting nicer. The patient refused reexamination, "(patient) just wanted their stuff and to leave." Patient signed out AMA after risks and benefits were explained to them. The patient was transported back to RCF by LE.

7. During an interview 8/15/24 at 2:30 PM with Staff C ED Registered Nurse/Manager, recalled, Patient #18 had no indications that they were suicidal and was in the ED for assault. Columbia suicide and Broset screening were negative for violence or suicide. Per Mental Health Policy 1:1 sitter was not indicated per violent and suicide score. "There was a mandate for the RCF where the patient was residing, not for the hospital." Staff C stated "The RCF had the responsibility to notify us if the patient had a mandate and any concerns of mental health issues when sending them to the ED." ED had the capability of providing 1:1 sitter at any time. Would call staff down from the floor or ambulance personnel to sit with the patient. "We do what we can within our capabilities to have a sitter for the patient. Even if that means calling in additional staff to cover the 1:1 sitter."

8. During an interview on 8/13/24@ 11:22 AM Program Manager at Residential Care Facility (RCF). Patient #18 had been a the facility for a couple of days; admitted on 1/8/2024. Patient #18 was admitted to the RCF here on a mandate from a County Court for mental health. The patient had a substance abuse history of Cannabis, Amphetamines and Methamphetamines. Active medical history of Psychoactive Substance dependence, unspecified psychosis and bipolar disorder. Patient was pregnant and delivered the child prior to June 24, 2024 at Hospital B (indicative that the patient was 12 weeks pregnant at the time of the ED visit on 1/14/24).

9. During an interview on 8/12/24 with Staff I ED Registered Nurse, Manager in Training, during ED tour was asked about the arrival of Obstetric (OB) patients and how triaged. OB patients were seen in the ED. If an OB patient was 20 weeks or greater they could have also been taken to the OB floor for examination. To ensure safety of the patient who arrived in the ED with a behavioral health diagnosis, they were assessed and assigned 1:1 direct observation by hospital staff if needed. Hospital would call additional staff in for assistance. Court ordered patients had a 1:1 sitter by either law enforcement or nursing staff. Elopements happened and patients could not be held against their will. Staff made all attempts to keep the patient. If a patient eloped, law enforcement was contacted to locate the patient and return them to the ED. If a patient chose to leave, staff would explain the risks and benefits and have them sign the AMA form.

ED staff failed to perform a complete MSE on Patient #18. The ED Physician documented awareness of Patient #18's court committal to the RCF. ED staff failed to maintain the safety of the patient, within the hospital's capability, by preventing the patient from eloping from the ED. Patient #18 had been involved in a violent altercation prior to coming to the ED for medical treatment. Patient #18 expressed concern for the safety and well-being of their unborn child. ED staff failed to perform any type of testing to confirm the patient's pregnancy and well-being of the fetus including, but not limited to, laboratory testing to further assess the health status of the unborn child and the health and safety of the mother, use of a Doppler to check the status of fetus' heart rate and rhythm or the use of ultrasound imaging.