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Based on facility policy, medical staff bylaws and rules and regulations, medical record review, emergency department log and interview, the hospital failed to ensure all patients presenting to the hospital's Dedicated Emergency Department (DED) seeking medical treatment were provided an appropriate medical screening examination (MSE) for 2 of 21 (Patients #4 and 21) sampled patients and failed to ensure all patients were informed of risks and benefits of refusing a MSE and/or treatment for 4 of 7 (Patients #3, 7, 9, and 14) sampled patients.

The findings included:

1. Medical record review revealed Patient #4, a 12 year old minor, presented to the DED on 5/10/2022 accompanied by their grandmother, with complaints of an injury to their right hand. The grandmother was informed the patient could not be taken back into the DED until proof of custody could be provided to the DED.
The grandmother left and took Patient #4 to Hospital #2's DED where the patient received a MSE and was diagnosed with a displaced fracture.
Refer to A 2406

2. Medical record review revealed Patient #21, a 10 year minor, presented to the DED on 5/17/2022 accompanied by their grandmother, with complaints of a right arm injury after falling off the monkey bars at school. The grandmother was asked for proof of custody. The grandmother left the DED with the patient and stated she was going to another facility because "we never have this trouble" at another facility.
Refer to A2406

3. Medical record review revealed Patient #3, a 2 year old minor, presented to the DED on 5/10/2022 with the chief complaint of Back Pain post fall. The DED log revealed the patient left prior to medical screening.
There was no documentation in the medical record of the patient leaving in accordance with the facility policy.
Refer to A2407

4. Medical record review revealed Patient #7, a 5 year old minor, presented to the DED on 9/28/2021 with the chief complaint of falling of the playset at school. The DED log revealed the patient left prior to medical screening.
There was no documentation in the medical record of the patient leaving in accordance with the facility policy.
Refer to A2407

5. Medical record review revealed Patient #9 presented to the DED on 11/22/2022 with the chief complaint of Anxiety/Situational Crisis. The DED log revealed the patient left against medical advice (AMA). There was no documentation the patient was given specific risks/benefits in accordance with the AMA policy procedure.
Refer to A 2407

6. Medical record review revealed Patient #14, a 7 year old minor, presented to the DED on 3/31/2022 with the chief complaint of lower extremity injury. The DED log revealed the patient was "unassigned." Eleven (11) minutes after the patient's arrival, the patient was taken off the ED Triage Board. There was no documentation why the patient was taken off the Triage Board and no documentation why the patient did not receive a MSE or disposition of the patient.
Refer to A 2407

Based on facility policy, medical staff bylaws rules and regulations, record review, emergency department (ED) log, document review and interview, the facility failed to provide an appropriate medical screening examination (MSE) without proof of custody for 2 of 2 minor patients (Patients #4 and 21) presenting to the ED with a grandparent.

The findings included:

1. Review of the medical staff bylaws, rules and regulations revealed, "... Rules and Regulations ... Admissions and Discharge ... 2.9 ... All individuals presenting to the Hospital/Emergency Department who requests a non-scheduled examination and/or treatment shall receive a medical screening examination from a physician or qualified medical personnel (Nurse Practitioner, Doctor of Nursing Practice, Physician's Assistant or designated obstetrical registered nurse) to determine if an emergency medical condition exists ... Patients presenting with an emergency medical condition will receive treatment to stabilize the condition utilizing the capabilities and capacity of the medical center and the staff, including on-call physicians as needed ... "

2. Review of the "Triage Nurse, Guidelines For Duties" policy dated 2/26/2020 revealed, "... Complete triage on all patients and determine their triage level according to ESI (Emergency Severity Index) Standards. (Policy 6231.20.850) ..."

Review of the "Triage, Procedure For Emergency Severity Index (ESI)" reference 6231.20.850 dated 7/30/2019 revealed, "... The purpose of triage is to assign acuity to patients who present to the Emergency Department (ED) and to identify those who require the greatest number of resources ... Triage means: The priority given to an individual or individuals for diagnostic and therapeutic intervention in the ED. Triage evaluation is not equivalent to a Medical Screening Examination as it does not determine the presence or absence of an Emergency Medical Condition ..."

3. Review of the ED "Physician's Responsibility For Evaluation And Treating Patients" policy dated 8/26/2019 revealed, "... Policy... The Emergency Department is staffed by an onsite physician 24 hours per day. It is the responsibility of the physician to evaluate and treat as necessary all patients presenting to the Emergency Department."

4. Medical record review revealed Patient #4 was a 12 year old minor child and presented to Hospital #1's ED on 5/10/2022 at 19:22. Registered Nurse (RN) #1 performed the triage assessment for Patient #4 at 19:30 and the chief complaint was upper right hand injury resulting from catching a softball with their bare hand. The patient had a pain level of 7 out of 10, with 10 being the worst pain. The triage assessment revealed the 12 year old presented from home and was accompanied by a family member.

Medical record review revealed at 19:57 RN #1 documented, "... pts [patient's] parent very upset because she was informed that until she can prove that she is the adoptive parent the patient can not be taken to the back [ED examination rooms]. the patient was triaged with minor injury and the mother told 3 times that she needed to produce the paperwork proving adoption, in order to be seen in the back, that we would be happy to see her if she can prove custody., [sic] she said they [custody papers] were at home and she was not going to wake her husband to get them up here. she took the pt to another hospital, stating that we were refusing treatment."

Review of the ED log revealed Patient #4 "Left Prior to Medical Screening."

Medical record review revealed at 20:02 RN #2 documented, "... attempted to call pt from waiting room. Registration states patient has left."

There was no documentation that Patient #4 received a Medical Screening Examination at Hospital #1.

Review of Hospital #2's medical record for Patient #4 revealed the 12 year old patient presented to Hospital #2's ED on 5/10/2022 and triaged at 21:18 with the chief complaint of pain in right hand. The medical record documented, " ...Parents state they took her to [Name of Hospital #1] but they refused to see her because she did not have her adoption papers ..."

The ED physician saw Patient #4 at 22:55 and documented, " ...The patient caught a softball with her right hand. Acute right 3rd finger pain and swelling ... Location: right 3rd finger. The character of symptoms is pain and swelling..." The physician ordered an x-ray to the right hand. The patient complained of moderate pain and was administered Ibuprofen 400 milligrams (mg), Norco 5mg/325 mg, and Zofran 4 mg.

Review of the right hand x-ray results revealed a mildly displaced intra-articular fracture involving the volar base of the distal 3rd phalanx with regional soft tissue swelling.

The ED physician documented the patient was discharged with a finger splint to the right 3rd finger and a prescription for Norco 5mg/325 mg.

In an interview in an administrative conference room on 5/19/2022 at 8:10 AM Hospital #1's ED Director verified Patient #4 did not receive a MSE at Hospital #1.

In a telephone interview on 5/19/2022 at 10:50 AM RN #1 was asked about Patient #4 presenting to the ED on 5/10/2022 with the grandmother and RN #1 stated, " I said she had to have proof that she was the one with custody."
RN #1 was asked about the note documented on 5/10/2022 at 19:57 and RN #1 stated, " If I documented it, then that is what I said."

In a telephone interview on 5/19/2022 at 10:55 AM, RN #2 was asked about the nursing note documented on 5/10/2022 at 20:02 and RN #2 stated she went to call the patient back to the ED and she [Patient #4] was gone.
RN #2 was asked if she knew that the patient was refused a MSE because the grandmother could not show proof of custody and RN #2 stated, "No ma'am."

In a telephone interview on 5/19/2022 at 11:01 AM, Physician #1 was asked if he knew anything about Patient #4 being denied a MSE due to grandmother was unable to provide custody papers and Physician #1 stated he was not aware of the situation on the day it occurred on 5/10/2022.

In a telephone interview on 5/19/2022 at 10:55 AM, FNP #1 was asked if she was aware of Patient #4 being denied a MSE on 5/10/2022 due to inability to provide custody papers and FNP #1 stated she did not recall Patient #4, but recently had a similar incident with a child [Patient #21] presenting to the ED with arm pain. FNP #1 stated, "The child's grandmother said she had custody but didn't have proof". FNP #1 stated that at Registration, the grandmother was told she would have to provide papers to prove she had custody in order for the child to be examined at the ED.

5. Medical record review for Patient #21 was a 10 year old minor child and presented to Hospital #1's ED on 5/17/2022 at 16:20 with a grandparent. RN #1 performed the triage assessment for Patient #21 at 16:43 and the chief complaint was upper right arm injury. RN #1 documented, " ... on monkey bars, fell hit arm on the pole and onto dirt. c/o [complains of] right forearm pain." The patient complaint of pain at a level 5 out of 10, with 10 being the worst pain.

Review of an unsigned note dated 5/17/2022 at 16:55 which documented, "16:55 FNP NOTIFIED OF PT [Patient #21] NEED FOR MEDICAL SCREENING. NOTIFIED GRANDMOTHER THAT A PROVIDER WOULD BE COMING TO SPEAK WITH HER AS SOON AS SHE COULD. GRANDMOTHER STATES WE CAN HAVE HER DAUGHTER NUMBER BUT SHE WOULD NOT GUARANTEE WHAT CONDITION SHE WOULD BE IN OR IF WE COULD REACH HER "

Review of a nursing note by RN #3 dated 5/17/2022 at 17:21 RN #3 revealed "... pt grandmother brought patient to ed [ED] to be seen after falling off monkey bars at school. patient's grandmother does not have custody or guardian paperwork, but states they just moved here from [another county in TN], and she has never had to have papers before ... pt was triaged and then grandmother produced a phone number to the patient's mother. attempted to call mother for permission to treat and there was no answer ... the patient's grandmother told registration they were leaving because 'we never have this trouble at [name of an urgent care clinic] and it's not hurting that bad ..."

There was no documentation that Patient #21 received a Medical Screening Examination at Hospital #1 or the risks and benefits of leaving without treatment was explained to the patient's grandmother.

In a telephone interview on 5/19/2022 at 1:54 PM the registration staff working on 5/17/2022 was asked about Patient #21 presenting with their grandmother. The registration staff member stated, "... I asked her if she had POA [Power of Attorney] papers to show custody and guardianship...She [grandmother] came out and said she was going to fast pace because they didn't give her any issues to treat the grandson. "
The registration staff member stated, " they are supposed to be verified that they have permission to bring the child in for treatment. When she came in she said she was the grandmother. I asked if the mother is coming to verify".

In a telephone interview on 5/19/2022 at 2:03 PM RN #1 was asked about Patient #21. RN #1 stated it was the same situation as Patient #4. RN #1 stated, "I told her [grandmother] the situation that we needed proof of custody, but we would do a medical screening to see if he had an emergency ..."

In a telephone interview on 5/19/2022 at 2:41 PM RN #3 was asked about Patient #21. RN #3 stated, "I know after I talked to the grandmother that I talked to the Nurse Practitioner. The grandmother kept changing her story, she had adopted her grandson, then she said I care for him and then she said to just call his mom maybe she will be in a shape to talk to you." RN #3 stated after she talked with the Nurse Practitioner, was when the facility contacted Child Protective Services.

Based on facility policy, medical staff bylaws and rules and regulations, medical record review, emergency department log, and interview, the hospital failed to ensure all patients (or a person acting on the individual's behalf) were informed of the risks and benefits for refusal of the examination and/or treatment for 4 of 7 (Patients #3, 7, 9, and 14) sampled patients reviewed for refusal.

The findings included:

1. Review of the medical staff bylaws, rules and regulations revealed, "... Rules and Regulations ... Admissions and Discharge ... All individuals presenting to the Hospital/Emergency Department who requests a non-scheduled examination and/or treatment shall receive a medical screening examination from a physician or qualified medical personnel (Nurse Practitioner, Doctor of Nursing Practice, Physician's Assistant or designated obstetrical registered nurse) to determine if an emergency medical condition exists ... Patients presenting with an emergency medical condition will receive treatment to stabilize the condition utilizing the capabilities and capacity of the medical center and the staff, including on-call physicians as needed ... "

2. Review of the "EMTALA Patients Who Leave the Hospital Against Medical Advice or Without Being Seen by a Physician or Qualified Medical Personnel" policy dated 7/31/19 revealed, "...Purpose: To ensure consistent procedures are followed when patients choose to leave HCMC dedicated Emergency Department ("DED"), against medical advice ("AMA") or without being seen by a physician or Qualified Medical Personnel ("QMP") ... Procedure ...
A. Leaving DED Prior to Triage: If an individual presents to the DED and requests care/services for a medical condition, but the individual desires to leave prior to triage, the facility should ... the risks and benefits associated with leaving prior to receiving a medical screening examination ("MSE") must be discussed with the individual if the patient's reason for presenting for treatment is known ... If the individual still desires to leave, the individual should be asked to sign the Refusal of Examination and Treatment for Emergency Medical Condition form. If the individual does not sign the form, the individual's refusal should be documented ... If the individual leaves without notifying anyone, documentation of the attempts to locate the individual should be recorded in the medical record and status noted on the ED log ...
B. Leaving DED after triage but before an MSE: If an individual presents to the DED and requests care/services for a medical condition, is triaged, and then indicates a desire to leave prior to the MSE, the facility should ... Create a medical record ...Triage documentation ... Offer the individual further medical examination and treatment ... Discuss with the individual the risks and benefits involved in leaving prior to the MSE and document this in the medical record ... Advise individual of treatment options if condition worsens or if they change their mind ... Take all reasonable steps to secure the individual's written informed consent to refuse or withdraw ...Document the individual's refusal of MSE, or the attempts to locate the individual if he or she left without notifying someone ... Describe, in the medical record, the examination and treatment that was refused or the request for treatment was withdrawn ... Sign the form, adding date and time ...
C. Leaving DED after the MSE: For those individuals indicating a desire to leave the DED against medical advice ("AMA") after receiving a MSE, the facility should ... Offer the individual further medical examination and treatment as may be required to identify and stabilize the emergency medical condition ... Discuss with the individual the risks and benefits and document in the medical record ... Advise individual of treatment options if condition worsens or if they change their mind about seeking treatment ...Take all reasonable steps to secure the individual's written informed consent to refuse ...This document should be included with the medical record ..."

3. Medical record review revealed Patient #3, a 2 year old minor, presented to the ED on 5/10/2022 at 16:10 with the chief complaint of Back Pain post fall. The triage assessment was conducted at 16:19 by Registered Nurse (RN) #1. RN #1 documented, "Tried to jump to a pole and fell to the ground. And now is c/o [complaining of] his lower back. Painful ambulation ..."

Review of the ED log revealed Patient #3 "Left Prior To Medical Screening."
There was no documentation included in the medical record of why the patient left and did not receive a MSE or documentation the risks and benefits were explained prior to the patient leaving..

In an interview on 5/19/2022 at 8:10 AM in the conference room the ED Director verified there was no documentation or form completed to explain the circumstance of the patient leaving before receiving a MSE.

4. Medical record review revealed Patient #7, a 5 year old minor, presented to the ED on 9/28/2021 at 14:50 the chief complaint of "Fall: fell off playset at school." The triage assessment was conducted at 14:56 by RN #4. RN #4 documented, "Fell while at school, hit head. School gave ibuprofen for headache. Vomited x 1 while at school. Mother states child has been acting inappropriate. Laughing and playing while in triage."

Review of the ED log revealed Patient #7 "Left Prior To Medical Screening."
There was no documentation included in the medical record of why the patient left and did not receive a MSE, or documentation the risks and benefits were explained prior to the patient leaving..

In an interview on 5/19/2022 at 8:10 AM in the conference room the ED Director verified there was no documentation or form completed to explain the circumstance of the patient leaving before receiving a MSE.

5. Medical record review revealed Patient #9 presented to the ED on 11/22/2021 at 11:34 the chief complaint of "Anxiety / Situational Crisis." The triage assessment was conducted by RN #4. RN #4 documented, "Is doing a rehab program through the [name of County] Jail. Phases to freedom life recovery ... states patient was possibly given drugs ... Since Saturday patient has been aggressive with other patients at facility and has threatened to kill one other patient, also made a statement that she wanted to hurt herself ... "

On 11/22/2021 at 12:30 PM RN #4 documented, "Patient has left ER lobby twice, instructed to come back inside twice. Nurse was attempting to get an open room to put patient in for evaluation and she [Patient #9] left the ER for a third time. Nurse could not find patient inside immediate ER parking lot. [Name of Department] police notified, instructed to call Sheriffs department ... Spoke with [name of Captain] and informed him that patient was brought to ER for suicidal and homicidal ideations but patient refused to stay in ER and had left at this time ... "

Review of the ED log revealed Patient #9 "Left A.M.A. [Against Medical Advice]"

In an interview on 5/19/2022 at 8:10 AM in the conference room the ED Director verified there was no documentation the AMA form had been completed or that medical advice had been given to the patient and/or custodian before Patient #9 left the ED.

6. Medical record review revealed Patient #14, a 7 year old minor, presented on 3/31/2022 with lower extremity injury. Review of the ED log revealed the patient was "unassigned."

In an interview on 5/19/2022 at 9:45 AM in the conference room the ED Director stated the patient was taken off the ED triage board 11 minutes after registering. There was no additional documentation to explain the circumstance of the patient leaving before receiving a MSE and why the patient was taken off the ED triage board.