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Based on reviews of medical records, Pre Hospital Report, policy and procedure and interviews, St. Joseph Hospital - Savannah failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medicinal condition exists for one (1) (patient # 7) of twenty (20) sampled medical records. Refer to findings in tag A-2406.
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Based on reviews of medical records, Pre-Hospital Report, policy and procedure and interviews, St. Joseph Hospital - Savannah failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medicinal condition exists for one (1) (patient # 7) of twenty (20) sampled medical records.

Findings include:


Review of policy number 1102-A, EMTALA- Emergency Medical Treatment and Active Labor Act, effective date 10/14/2014, revealed:
· Any individual who comes to the dedicated emergency department (DED) requesting examination or treatment would be provided with an appropriate medical screening examination by qualified medical personnel (QMP)
· The medical screening examination (MSE) should include ancillary services where appropriate and routinely available to the DED, and be similar for patients presenting with similar symptoms
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· If a patient withdraws his/her request for examination or treatment, a QMP (qualified Medical Personnel) from the DED (Dedicated Emergency Department) staff would discuss the medical issues related to a "voluntary withdrawal", and would offer the patient further medical examination and treatment as required to identify and stabilize an EMC; inform the patients of the benefits of continued treatment/risks of withdrawing treatment; request the patient sign an a Refusal for Medical Treatment form; notify the DED physician of patient's intent to leave
· If patient leaves the DED prior to the MSE or stabilizing treatment without notifying Hospital personnel, it should be documented, and the DED notified the the patient left AMA. The documentation must reflect that the patient had been at the hospital and the time the patient was discovered to have left the premises.


Review of patient #7's Pre Hospital Report dated 10/7/2014 revealed that Emergency Management Service (EMS) was called " for a reported hypertension." On arrival at 11:35 p.m. EMS reported in part, "Found a 34 year old patient (# 7)...Chief complaint of HYPERTENSION ...Standing at road with suitcase in hand stating a need to go to St Joseph." Review of the Paramedic assessment included patient (# 7) was oriented to person, place, time with a blood pressure (BP) reading at 11:49 p.m. 181/102 (normal range 120/80) and then at 11:54 p.m. BP of 160/110. The Paramedic also documented that Patient #7 had a medical history of Hypertension, Bipolar, Schizophrenia, and Manic Depressive Disorder. Enroute EMS notified the hospital of patient # 7's condition. EMS recorded an arrival time at the hospital at 12:03 a.m., patient # 7 was delivered to Emergency Room (ER) room 1 and verbal report given to nursing staff.

Review of the Emergency Room record revealed that patient #7 arrived to St. Joseph Hospital-Savannah pm 10/8/2014 at 12:10 a.m. Review of a nurses noted dated 10/8/2014 at 1:20 am indicated in part, "Per____ (name), immediately after taking Vital Signs the Pt (patient #7) walked out of the door without saying anything. Pt has not been triaged." Documentation on Emergency Room record, revealed "Discharge Date/Time 10:08/14 01:20 - Discharge Disposition Home, Self-care ... Status Left Department." There was no documentation in the medical record to indicate that on 10/7/2014 Patient #7 was informed by a QMP from the DED of the benefits of continued treatment/risks of withdrawing treatment as stated in the facility's policy, after the nurse saw the patient leaving out of the door after taking his vital signs.


Review of the receiving hospital ER record dated 10/8/2014 at 4:56 a.m. revealed that patent # 7 arrived at the facility with complaints of feeling suicidal and that the patient reported being at St. Joseph Hospital - Savannah and threatened one of the staff members who called the police and the police brought the patient here (receiving hospital) for evaluation. Continued review of the ED record revealed that patient # 7, was very argumentative and agitated, and refused to give information, arrived by police escort from St. Joseph Hospital - Savannah. Documentation by the ED physician revealed, " Physical exam: BP 153/95, Pulse 82, Tem (temperature) 97.7 Resp (respirations) 18 ... Pt not appearing well...Psychiatric: Bizarre behavior. Bizarre mood. Difficulty understanding speech, Complaining of suicide ideation ...MDM (medical decision making) ...Depression: established and worsening Drug Abuse established and worsening Hypertensive urgency and requires workup Suicide ideation established and worsening ...Clinical lab tests: ordered and reviewed ...Discussed the patient with other providers ...Consults: psychiatry ...Psychiatry team consult. 1013 (legal authority to hold a person for behavioral assessment due to behavior which might be dangerous to self or others) performed. ..Medical Records reviewed patient evaluated. Psychiatric evaluation performed. The patient will be admitted ...The patient did have an elevated blood pressure. This was discussed with the patient (#7). He has been noncompliant with his clonidine (medication used to treat high blood pressure). He was given 0.3 mg of clonidine here. This seemed to work well. His blood pressure did start to come down. The patient was admitted to another hospital (psychiatric unit) for depression and suicidal ideation."



Interview (via telephone) with Registered Nurse (RN) #3 on 11/14/14 at 3:05 p.m. revealed if a patient came in/brought in by EMS with a report of suicidal or homicidal ideation's (S.I./H.I.) or danger to self/others, any nurse who received the report would have EMS bypass triage and bring patient straight back so they could be watched by security, evaluated, and possibly have a 1013 initiated (order for involuntary hold to provide behavioral health assessment for patients who appear to be a danger to self or others). EMS could speak to the ER physician to obtain orders in the field. If the patient's BP was 160-180 without symptoms (HA, numbness blurred vision) MD might not treat the patient, might just watch to see if it comes down on it's own since it may be the result of agitation, pain etc.

Interview with ER Nurse Manager on 11/14/14 at 3:30 p.m. revealed that hospital does not get a lot of homeless patients seeking shelter/food. Patients with complaint of SI or HI would go straight back to a room; nurse would receive the patient, perform an assessment, and check for contrabands (weapons, drugs, medication, etc). Security would be notified to come to the ER. Protocol/standing order is for specific laboratory specimens to be drawn to medically clear the patient in case they are to be committed to a facility. The ER physician would assess the patient for possible initiation of 1013. If a consult is ordered for a behavioral health assessment, the contracted service has one (1) hour to get here.


The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that a medical screening examination was provided for patient #7 on 10/8/2014 that was within the capability of hospital's ED to determine whether or not an emergency medical condition existed when he presented with signs of hypertension and with a known history of mental illness.