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Based on observation, interview, and record review, the facility failed to ensure the Central [EMTALA - Emergency Medical Treatment and Labor Act] Log contained accurate information on the disposition of one of 26 sampled patients [Patient 1]. This resulted in the disposition for Patient 1 being documented as "eloped [seen by provider]/LBTC [left before treatment completed]" when the patient was observed being removed from the facility Emergency Department [ED] Lobby via a wheelchair by two Security Officers prior to a medical screening examination by a provider.

Findings:

Unannounced onsite investigations were conducted at the facility on April 7 and 27, 2021, and the record for Patient 1 was reviewed. Patient 1 was brought in by an ambulance and presented to the facility ED on April 3, 2021, at 7:23 p.m.

The "ED Record Nursing Chart," dated April 3, 2021, indicated the following:

- At 7:35 p.m., the initial vital signs upon presentation were as follows:
-- Blood pressure 162 mmHg[millimeters of mercury]/78 mmHg [normal blood pressure below 120/80 mm Hg and above 90/60 mm Hg], taken while patient was sitting;
-- Temperature 98° F [Fahrenheit - normal temperature 98.6° F];
-- Heart rate 116 [normal heart rate 60 to 100 beats per minute], sitting, awake;
-- Respiratory rate 18 [normal respiratory rate 12 to 16 breaths per minute];
-- Oxygen saturation 98% [normal oxygen saturation between 97 percent [%] and 99%]; and
-- Pain was 8 [on a scale of 0 to 10 with 10 being the worst pain].

- At 7:36 p.m., Patient 1 was in ED Room 3, and the triage assessment indicated the chief complaint was spontaneous generalized headache which had an onset five days prior and there was associated nausea. The triage acuity was "3 (Urgent);" and

- At 7:40 p.m., "...Disposition: Eloped/LBTC...Attempts were made to call the patient..."

On April 7, 2021, at 11:30 a.m., the security video tapes from April 3, 2021, were reviewed with the Patient Relations & Risk Manager [PRRM] and the Chief Nursing Officer [CNO].

[On April 12, 2021, at 1:14 p.m., confirmation was obtained from the PRRM that the time of the video recordings was off by 7 minutes. Real time was 7 minutes ahead of the video/camera recorded time.]

The following was observed when reviewing the video camera recordings:

- At 7:16 p.m. [corrected real time - 7:23 p.m.], Patient 1 was observed entering the facility on a gurney accompanied by two ambulance attendants.
- At 7:24 p.m. [corrected real time - 7:31 p.m., 8 minutes later], Patient 1 was wheeled out of the ED in a wheelchair to the Lobby;
- At 7:25 p.m. [correct real time - 7:32 p.m.], Admitting Clerk [AC] 1 was seen speaking with Patient 1 and the patient's head was bobbing up and down without an active response to AC 1's questions;
- At 7:25 p.m. [corrected real time - 7:32 p.m.], Security Officer [SO] 1 was subsequently seen speaking with Patient 1 and no response/movement was observed from the patient;
- At 7:30 p.m. [corrected real time - 7:37 p.m.], SO 1 was seen speaking with the Admitting Supervisor [AS];
- At 7:32 p.m. [corrected real time - 7:39 p.m.], Patient 1 was seen being wheeled out of the ED Lobby by SO 1, with his bare left foot [anterior side down] dragging on the ground; and
- At 7:32 p.m. [corrected real time - 7:39 p.m.], SO 1, SO 2, and the Admitting Supervisor [AS] were seen talking outside the ED Lobby doors with Patient 1 in the facility wheelchair. The AS was seen proceeding to the left. SO 1 and SO 2 were seen pushing Patient 1 in the facility wheelchair and proceeding to the right towards the medical office buildings and the street.

On April 7, 2021, at 1:15 p.m., additional security video tapes from April 3, 2021, were reviewed with the PRRM and the CNO.

The following was observed when reviewing the video camera recordings:

- At 7:37 p.m. [corrected real time - 7:44 p.m.], SO 1 and SO 2 were seen returning to the ED Lobby entrance with an empty wheelchair; and
- At 7:38 p.m. [corrected real time - 7:45 p.m.], SO 1 and SO 2 were seen entering the ED Lobby.

The facility "Emtala log," dated April 3, 2021, indicated Patient 1's arrival time as 7:25 p.m., the chief complaint as "headache," and the status as "Eloped/LBTC" on April 3, 2021, at 7:40 p.m.

During an interview with the PRRM, on April 27, 2021, at 10:23 a.m., she defined the following terms as used by the facility:

- Eloped: seen by a physician/provider;
- LWBS: left prior to medical screening exam; and
- LBTC: left before treatment completed.

In addition, the PRRM stated LBTC should not be used, and either eloped or LWBS should be used as appropriate for the patient's disposition.

During a subsequent interview with the PRRM, on April 28, 2021, at 9:15 a.m., she verified Patient 1's disposition was entered by the Triage Registered Nurse [TRN] and did not accurately reflect what had occurred with the patient. The PRRM stated the EMTALA Log should accurately indicate what occurred with the patient.

The facility policy and procedure titled, "Examination, Treatment & Transfer of Emergency Department Patients (EMTALA)," last revised by the facility September 2019, was reviewed on April 28, 2021. There was no documented indication of the requirement for a Central Log, the required elements of a Central Log, and the accuracy of documentation placed in the Central Log.

Based on observation, interview, and record review, the facility failed to ensure a medical screening examination was provided to one of 18 sampled patients [Patient 1] who presented to the facility Emergency Department [ED] for care and treatment. This resulted in Patient 1 being physically removed from the facility prior to a medical screening exam and the subsequent death of Patient 1.

Findings:

On April 7 and 27, 2021, the record for Patient 1 was reviewed. Patient 1 was brought in by an ambulance and presented to the facility ED on April 3, 2021, at 7:23 p.m.

The "(Name of the ambulance company) Patient Care Report," dated April 3, 2021, indicated the following:

- At 6:58 p.m., prior to the ambulance arrival, Patient 1 was assessed by another Emergency Medical Services Agency, and the patient's heart rate was 79 beats per minute [normal heart rate 60 to 100 beats per minute (bpm)] with an oxygen saturation of 83% [normal oxygen saturation between 97 percent (%) and 99%];

- At 7:04 p.m., the ambulance arrived at Patient 1 who was lying down. Patient 1 made the following statements: "Take me to [Name of Facility], I just don't feel well" and "I've been up and doing drugs for the last five days;"

- At 7:05 p.m., Patient 1's heart rate was 160 bpm, oxygen saturation was 82%, respiratory rate was rapid at 30 breaths per minute [normal respiratory rate 12 to 16 breaths per minute], and the Glasgow Coma Scale [GCS - used to reliably measure a person's level of consciousness. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. These three behaviors make up the three elements of the scale: eye, verbal, and motor. A person's GCS score can range from 3 (completely unresponsive) to 15 (responsive)] score was 15. Patient 1's chief complaint was "feeling sick" with the primary symptom of abnormal behavior. Other symptoms included visual and auditory hallucinations [seeing and hearing things which occur without an actual external stimulus] and an impression of "Overdose/Poisoning/Ingestion; Cardiac arrhythmia [condition in which the heart beats with an irregular or abnormal rhythm];"

- At 7:10 p.m., Patient 1's heart rate was 159 bpm, oxygen saturation was 71%, respiratory rate was 30 breaths per minute, and the GCS score was 15. Patient 1 was "extremely agitated and restless;" skin was pale, dry and warm, and pupils were pinpoint;

- At 7:13 p.m., the ambulance personnel were transporting the patient. Patient 1 was restless and would not sit still, constantly changing positions, and was hallucinating thinking his mother was with him which she was not;

- At 7:22 p.m., the ambulance with Patient 1 arrived at facility desk. The facility ED Charge Nurse asked the ambulance personnel if Patient 1 had an intravenous [IV - delivery of fluid and medications directly into a vein] and they responded no. The ED Charge Nurse replied, "Put him in the lobby." Patient 1 stood up, walked back and forth, sat in the wheelchair, and was taken out to the ED lobby. Once the patient was in the lobby in the wheelchair, Patient 1 "became very quiet and calm;"

- At 7:38 p.m., care of Patient 1 was transferred by the ambulance staff to the facility. Report was given to the receiving Triage Registered Nurse [TRN] to include the patient's heart rate of 160 on the radio call in and in person; and

- At about five minutes after transfer of care, the ambulance personnel witnessed two security guards escorting Patient 1 out of the facility in a wheelchair and onto the sidewalk.

The facility "Emtala log," dated April 3, 2021, indicated Patient 1's arrival time as 7:25 p.m., the chief complaint as "headache," and the status as "Eloped/LBTC [left before treatment completed]" on April 3, 2021, at 7:40 p.m.

The ED "Nursing Chart," dated April 3, 2021, indicated the following:

- At 7:35 p.m., the initial vital signs upon presentation were as follow:
-- Blood pressure 162 mmHg[millimeters of mercury]/78 mmHg [normal blood pressure below 120/80 mm Hg and above 90/60 mm Hg], taken while patient was sitting;
-- Temperature 98° F [Fahrenheit - normal temperature 98.6° F];
-- Heart rate 116 bpm, sitting, and awake;
-- Respiratory rate 18 breaths per minute;
-- Oxygen saturation 98%; and
-- Pain was 8 [on a scale of 0 to 10 with 10 being the worst pain];

- At 7:36 p.m., Patient 1 was in ED Room 3, and the triage assessment indicated the chief complaint was spontaneous generalized headache, which started onset five days prior and there was associated nausea. The triage acuity was "3 (Urgent);" and

- At 7:40 p.m., Patient 1 eloped and attempts were made to call the patient.

There was no documented evidence a medical screening exmination was provided to Patient 1.

On April 7, 2021, at 11:30 a.m., the security video tapes from April 3, 2021, were reviewed with the Patient Relations & Risk Manager [PRRM] and the Chief Nursing Officer [CNO].

[On April 12, 2021, at 1:14 p.m., confirmation was obtained from the PRRM that the time of the video recordings was off by 7 minutes. Real time was 7 minutes ahead of the video/camera recorded time.]

The following was observed when reviewing the video camera recordings:

- At 7:16 p.m. [corrected real time - 7:23 p.m.], Patient 1 was observed entering the facility on a gurney accompanied by two ambulance attendants;

- At 7:24 p.m. [corrected real time - 7:31 p.m., 8 minutes later], Patient 1 was seen being wheeled out of the ED in a wheelchair to the Lobby;

- At 7:25 p.m. [correct real time - 7:32 p.m.], Admitting Clerk [AC] 1 was seen speaking with Patient 1 and the patient's head was observed bobbing up and down without an active response to AC 1's questions;

- At 7:25 p.m. [corrected real time - 7:32 p.m.], Security Officer [SO] 1 was subsequently seen speaking with Patient 1 and no response/movement was observed from the patient;

- At 7:30 p.m. [corrected real time - 7:37 p.m.], SO 1 was seen speaking with the Admitting Supervisor [AS];

- At 7:32 p.m. [corrected real time - 7:39 p.m.], Patient 1 was seen being wheeled out of the ED Lobby by SO 1, with his bare left foot [anterior side down] observed dragging on the ground; and

- At 7:32 p.m. [corrected real time - 7:39 p.m.], SO 1, SO 2, and the Admitting Supervisor [AS] were observed talking outside the ED lobby doors with Patient 1 in the facility wheelchair. The AS was seen proceeding to the left. SO 1 and SO 2 were seen pushing Patient 1 in the facility wheelchair and proceeding to the right towards the medical office buildings and street.

On April 7, 2021, at 1:15 p.m., additional security video tapes from April 3, 2021, were reviewed with the PRRM and the CNO.

The following was observed when reviewing the video camera recordings:

- At 7:37 p.m. [corrected real time - 7:44 p.m.], SO 1 and SO 2 were seen returning to the ED Lobby entrance with an empty wheelchair;

- At 7:38 p.m. [corrected real time - 7:45 p.m.], SO 1 and SO 2 were seen entering the ED Lobby; and

- At 7:39 p.m. [corrected real time - 7:46 p.m.], ED Technician 1 was seen entering the ED Lobby from the ED and moving around the waiting room area. SO 1 was seen speaking with ED Technician 1 and pointing out to the parking lot/street area between the facility and a park across the street.

During a concurrent interview, the PRRM and the CNO stated Patient 1 was found across the two lane street, where the Security Officers had left him, in the grass area before the Park sidewalk.

During an interview with AC 1, on April 7, 2021, at 4:03 p.m., she stated she registered Patient 1 in the ED unit, on April 3, 2021. AC 1 stated Patient 1 was "altered out of it," was having a hard time standing up, was off balance, and was falling down. AC 1 stated Patient 1 was placed in a wheelchair and the ambulance attendant was instructed to take Patient 1 to the ED Lobby. AC 1 stated she did not know what to put on the admission face sheet as the chief complaint and the ambulance attendant said the patient was having hallucinations and was high on methamphetamines [potent central nervous system (CNS) stimulant mainly used as a recreational drug]. AC 1 stated she tried to ask Patient 1 questions while he was in the ED Lobby such as a telephone number for next of kin, and he was just staring at the ground and was not responsive to her questions. AC 1 stated Patient 1 was not wearing a mask and SO 1 asked what should he do. AC 1 stated she referred him to the Admitting Supervisor [AS], who spoke with SO 1, and shortly after this she saw SO 1 wheeling Patient 1 out the door of the ED Lobby. AC 1 stated she asked why Patient 1 was being taken outside but did not receive an answer. AC 1 stated a Fire Fighter came in on April 3, 2021, at approximately 9:47 p.m., asking about Patient 1 and she told him, per the ED tracking system, Patient 1 had "eloped" at 9:27 p.m.

According to the Coroner's Office, during a telephone call on April 12, 2021, at 11:25 a.m., Patient 1 was pronounced dead by the Coroner/Sheriff on April 3, 2021, at 9:24 p.m. [1 hour and 45 minutes after being escorted off the property prior to being seen by a provider for an emergency medical condition].

During an interview with SO 1, on April 12, 2021, at 2 p.m., he stated on April 3, 2021, Patient was wheeled to the ED Lobby by an ambulance attendant. SO 1 stated Patient 1 was sitting in the wheelchair in the ED Lobby when he noticed the patient was not wearing a mask. SO 1 stated if a patient was waiting in the ED Lobby, they had to wear a mask. SO 1 stated Patient 1 was breathing heavily, grunting, mumbling, looking down, not responding to his request to put on a mask even when he got a mask for him, and not moving. SO 1 stated he assumed the patient was mad. SO 1 stated all the patients/visitors in the ED Lobby were staring at him. SO 1 stated he saw the Admitting Supervisor [AS] and asked her what he should do about the patient not wearing a mask in the waiting room. SO 1 stated the AS stated let me speak with the medical staff. SO 1 stated when the AS returned, she told him to ask Patient 1 if he needed medical attention or wanted to see a physician, and if there was no response from the patient, to escort him off of the property. SO 1 stated he again tried to give the patient a mask but there was no response from the patient and he continued to breathe "hard." SO 1 stated he called SO 2 for assistance and they escorted the patient through the parking lot, to the sidewalk area that was across the street from the community park. SO 1 stated when he stopped the wheelchair and then released the brake, Patient 1 fell to the ground on his own, straight forward onto the grass and most of his face was covered. SO 1 stated they asked the patient if he was ok but he did not answer, was breathing heavily, and they left the patient on the grass. SO 1 stated he went back into the ED Lobby and spoke with ED Technician [EDT] 1 who was looking for Patient 1. SO 1 stated he told EDT 1, they had just escorted Patient 1 "off property."

During an interview with ED Technician [EDT] 1, on April 12, 2021, at 2:18 p.m., he stated on April 3, 2021, at approximately 7:47 p.m., he was in the ED Lobby looking for Patient 1 but he could not find the patient. EDT 1 stated he spoke with SO 1 who told him Patient 1 had "awoled [absent without leave - meaning someone was not where they were supposed to be]."

During an interview with Triage Registered Nurse [TRN], on April 12, 2021, at 1:35 p.m., he stated he was triaging another patient when Patient 1 arrived. The TRN stated he "just glanced at the patient" and looked at the monitor on the ambulance gurney. The TRN stated the patient said he had a headache in the frontal area and the order from the Emergency Department Charge Nurse was to move the patient to the ED Lobby. The TRN stated he assessed Patient 1 in the hallway, it was a "quick glance," and this was a common practice to see the patients in the hallway and then place them in the ED Lobby. The TRN stated after his initial triage, he did not see the patient again, did not look for the patient, and was told by the Security Officer that Patient 1 had "walked out."

During an interview with Emergency Department Charge Nurse [ED Charge], on April 13, 2021, at 4:15 p.m., he stated he was the ED Charge Nurse on April 3, 2021. The ED Charge stated when Patient 1 arrived, they were busy with another ambulance run and asked the ambulance attendants if Patient 1 had an IV, what was the chief complaint, and were the patient's vital signs stable. The ED Charge stated he was told the patient was found injecting drugs and he heard the patient's heart rate was "116 bpm." The ED Charge stated he told the ambulance attendants to place Patient 1 in triage so he could be evaluated by the TRN. The ED Charge stated he did not know what happened with Patient 1 until after the Coroner/Sheriff came in to speak with the facility staff sometime after 9:30 p.m. on April 3, 2021. The ED Charge stated the Admitting Supervisor [AS] did come speak with him but he was not paying attention to her, did not remember responding to her, and did not speak with her directly. The ED Charge stated he was helping with another patient and that was his priority, the patients wearing masks in the ED Lobby was not important to him, and he did not tell the AS to put Patient 1 outside.

In addition, the ED Charge stated he was not aware of the patient's heart rate of 160 bpm, respiratory rate of 30 per minute, and oxygen saturation of 82% during transport to the facility. The ED Charge stated the Admitting Staff and Security Staff should inform the providers/nurses when a patient was not responsive in the ED Lobby. The ED Charge stated medical personnel did not have "eyes in the Lobby."

During an interview with the ED Unit Secretary [EDUS], on April 15, 2021, at 7:40 p.m., the EDUS stated he heard the ED Charge ask the ambulance personnel if Patient 1 had an IV and if his vital signs were stable The EDUS stated the ambulance personnel responded there was no IV and the patient's vital signs were stable. The EDUS stated he heard the ED Charge tell the ambulance personnel to place Patient 1 in triage to be evaluated. The EDUS stated the ED Charge was at the desk when the AS asked about the policy for patients wearing a mask. The EDUS stated the ED Charge replied the facility did not have a policy for patients in regards to wearing a mask and the staff could not force a patient to wear a mask.

In addition, the EDUS stated he did not see Patient 1 after his initial arrival, but the Coroner called on April 3, 2021, at approximately 9:43 p.m., asking if Patient 1 had been seen at the facility because he had a facility arm band on and that was how they identified the patient.

The facility policy and procedure titled, "Examination, Treatment & Transfer of Emergency Department Patients (EMTALA)," last revised by the facility September 2019, was reviewed. The policy indicated, "...No individual who requests services or care shall be transferred or discharged from this hospital before receiving a medical screening examination and appropriate stabilizing treatment if an emergency medical condition exists..."

The facility policy and procedure titled, "Triage," last reviewed by the facility July 2019, was reviewed. The policy indicated, "...All presenting patients will have a medical screening exam done by the Emergency Department Physician/Physician Assistant. Patients arriving via ambulance will be evaluated by the Charge nurse (or designated RN). Based on this assessment the patient will be placed in an exam room or may be escorted to triage for a complete triage assessment...Triage assessment: Perform focused assessment of chief complaint to include the collection of subjective and objective data...All patients must be weighed...Level 3- Urgent - Requires prompt care, but some delay will not cause loss of life or limb. These conditions require diagnostic and therapeutic intervention to prevent complications and relieve suffering. These are potentially serious nature...Document information accurately and legibly..."