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Based on staff interview, record review, and facility policy review, the facility failed to provide a Medical Screening Exam (MSE) for Patient #1, one (1) of 20 patients reviewed, during the patient's six (6) hour and four (4) minute wait in the Emergency Department.

Findings Include:

Cross Refer to A2406 for the facility's failure to provide a medical screening exam (MSE) for Patient #1 within the capability of the hospital ED.

Based on staff interview, record review, and facility policy review, the facility failed to provide a Medical Screening Exam (MSE) for Patient #1, one (1) of 20 patients reviewed, during the patient's six (6) hour and four (4) minute wait in the Emergency Department.

Findings Include:

Medical record review reveals Patient #1 was involved in a motor vehicle accident (MVA) on 11/07/2020 and was seen in the Emergency Department of Hospital #2.

Record review revealed Patient #1 entered Hospital #1 on 11/23/2020 at 11:20 a.m. complaining of neck pain, shoulder pain, and right knee pain. Record review reveals Patient #1 has a history of Bi-polar disorder. Record review revealed Patient #1 was triaged at 11:35 a.m. at a level of 4 and vital signs were taken and were within normal limits. Patient #1 was triaged non-urgent and was told to wait in the ED waiting area. Patient #1 allegedly walked up to desk to ask about her wait a few times. ED tech entered the ED waiting area around 4:32 p.m. to call back patients that have been there over four hours to re-take vitals and revaluate. Patient #1 refused to participate and started loudly cursing and threatening staff. A county deputy sheriff, who is stationed in the ED, asked Patient #1 to quiet down three (3) times. Patient #1 kept cursing and threatening loudly. Patient #1 was hand cuffed and escorted out of facility to jail prior to the required medical screening exam.

Review of intake form for this incident revealed patient alleged deputy at facility tried to choke and body slam her. Record review of Emergency Documentation (date 11/23/2020) reveled patient weight was 258 lbs. and five foot six inches tall. Intake information also revealed patient #1 went to another facility to check for possible injuries resulting from the deputy aggression in the ED.

Record review of ED visit Patient #1 presented to following her arrest, revealed they performed a gall bladder ultrasound, Computerized Tomography (CT) of chest and a chest x-ray which resulted in no acute injury, but was diagnosed as Costochondritis (inflammation of the cartilage that connects a rib to the breastbone).

INTERVIEWS AND RECORD REVIEWS

During an interview on 10/19/2021 at 2:43 p.m. with the Director of Customer Relations, states on 3/23/2021, Patient #1 contacted him via phone and spoke with him about her ED visit that was on 11/23/2020. Social Service employee #1 provided the Surveyor a copy of communication data as evidenced on the Patient Relations worksheet, event documentation, proof of mail correspondence and proof of returned mail correspondence.

During an interview with Registered Nurse (RN) #2 on 10/19/2021 at 2:58 p.m., employee recalled an incident of a patient that was arrested in November 2021 but is not able to recall the patient's name. Surveyor asked RN #2 to recall events from 11/23/2020. RN #2 verbalized she recalls triaging Patient #1 and was hard to deal with. Employee states she can recall the ED was very busy and she had many patients that had to have vital signs rechecked due to being in ED waiting for four (4) hours. These patients were previously triaged. "We had to recheck (Patient #1) vital signs and we were bringing patients back to recheck vital signs and the patient refused to come back for recheck of vital signs. Patient was belligerent to the nurse that wanted to recheck vital signs. The officer (County Sheriff Office) tried to calm her down three or four times. The patient was rude and loud to her and the officer. He (the officer) finally cuffed her. We were very scared and felt unsafe due to her behavior. The people in the waiting room voiced they were happy he (the officer) took care of the problem, they felt unsafe because this went on for three or four hours."

During an interview on 10/19/2021 at 3:15 p.m. with Clinical Technician, she reported that she was trying to repeat vital signs on patients that had previously been triaged and that remained in the waiting room. Employee stated, they must recheck vital signs every four hours. Clinical technician reports Patient #1 began cussing. Employee stated she did not engage her, and the Sheriff warned her three times to calm down, but the patient continued cussing. Even with kids and other patients in the waiting room, the patient continued this behavior. Clinical Technician reported she did not witness the officer being rough with her. She witnessed that the patient stood up, officer cuffed her, and she was escorted outside and recalls the patient cussing the entire time. Employee stated she felt scared and unsafe, but the Sheriff took care of her fears after seeing the patient escorted out. Clinical Technician reported, "I never seen anyone act like that.".

During interview on 10/19/2021 at 3:23 p.m., with Hospital Security Officer #1, employee stated he wrote a Security Event Report and provided Surveyor with a copy. This employee reported he did see Patient #1 voluntarily stand up. He can recall Patient #1 being very loud while in the waiting room.

During an interview with Chief Nursing Officer (CNO) on 10/20/2021 at 4:30 p.m., it was revealed that after having information technology (IT) involved and multiple other disciplines, they were unable to retrieve the video from 11/23/2020 since it had been so long ago.

POLICY REVIEW

Review of Facility Policy #471, "Triage revision (12/2018) revealed " ...to provide patient seeking emergency care appropriate and timely medical attention. An RN is assigned to the triage area 24 hours a day. The general qualifications recommended for all Emergency Department Nurses and especially ones following the triage role if ... The triage nurse should have flexibility and adaptability to meet the challenge of rapidly changing situation and recognize potentially life-threatening signs/symptoms provided by a patient to include abnormal vital signs ... be able to assign patient in an expeditious manner to the appropriate area to receive care in a timely manner ... All patients presented to the ED for care should be triaged upon arrival ... Patients presenting to the ED have a routine triage evaluation performed and entered on the patient's Electronic Health Record ... The five category Emergency Service Severity Index is used to assist with early recognition of patients with life-threatening disease, so that they will be treated prior to other patients presenting simultaneously, who have a lesser degree of illness ... Triage level four (semi urgent) ...patients in this category present with minor to chronic conditions that have low potential for deterioration or complications. Will have vital signs assessed as time permits and be reprioritized as warranted ...Vital signs should be reassessed as needed. Patient is assigned when a bed is available. The triage nurse or secondary triage personnel will monitor patients in the waiting room for treatment, and their acuity level will be repolarized (sic re-prioritize) if their reassessment warrants".

Review of facility policy entitled "(name of facility) Patient Care Manual" ... "SUBJECT: Medical Screening Examinations; Further Examination and Treatment; Transfer of Patients with Emergency Medical Conditions to Another Facility from Memorial" (revised 09/24/2018) Policy no. IV.09-A" revealed, page 4 of 7, " ...III. POLICY ...A. Any individuals requesting examination or treatment shall receive an appropriate Medical Screening Exam (MSE) (within the capabilities of the ED) to determine if an emergency medical condition exist ..." .

CONCLUSION

The state agency reviewed 20 Emergency Department patient records and confirmed the facility was not in compliance with 42 CFR 489.24, special responsibilities of Medicare Hospitals in emergency cases in one (1) out of 20 cases reviewed. Patient #1 did not receive an appropriate medical screening exam by a qualified medical provider prior to being removed from hospital property.