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Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they did not provide an appropriate medical screening examination (MSE) to rule out an emergency medical condition (EMC) within its capabilities and capacity, for four patient's (#22, #25, #27 and #29) out of 33 Emergency Department (ED) sampled cases from 08/27/22 through 02/27/23. The hospital failed to provide Patient's #22, #25, #27 and #29 with an adequate MSE, to include ancillary testing to rule out an EMC. Due to the lack of details obtained from not performing ordered lab work, radiology imaging and vital signs, the hospital did not have enough information to determine if the patients had EMCs that were stabilized to be safely discharged. The hospital's average monthly census over the past six months was 3,819.

Findings included:

Review of the hospital's policy titled, "EMTALA," revised 02/28/21, showed that any individual presenting to the hospital or dedicated ED, requesting emergency care, received a MSE to determine the presence of an EMC. A MSE was defined as an examination which is sufficiently detailed to reveal whether the patient suffers from an EMC and must include medical indicated screens, tests, mental status evaluations, history and physical examinations, etc. The MSE must be provided within the capability of the hospitals ED. Triage alone is not a MSE. An individual has the right to refuse a MSE.

Review of the hospital provided document titled, "Removal of Individuals from Emergency Department for Safety Reasons," revised 02/03/23, showed that upon identification of an individual in the ED that potentially required removal from the department for safety reasons, an ED staff member would notify the ED Charge RN and Security. Charge RN and Security shall rapidly respond to the area needed. Security Officer shall assist in de-escalation of the individual. If the individual was not a patient and does not request a medical evaluation the individual would be removed from the department. If the individual was a patient, the ED Charge RN would communicate with the medical staff and ensure that the individual had been evaluated by a qualified medical provider. If the patient had not already been evaluated, the qualified medical provider would evaluate the patient for any emergent medical condition. Upon determination that the patient did not have an EMC, and was unable to be de-escalated the individual would be escorted from the ED. After the patient was escorted from the ED, the Charge RN was to complete an event report and ensure ED Leadership was aware of the situation.

1. Review of Patient #22's ED record, showed:
- He was a 22-year-old male who presented to the ED on 01/03/23 at 10:55 PM, with a chief complaint of sexual assault.
- Past medical history included depression (extreme sadness that doesn't go away), human immunodeficiency virus (HIV, virus that attacks the cells that help the body fight infection), a learning disability, and SI. The charge nurse was notified of the need for a SANE evaluation.
- Several laboratory tests were ordered on 01/04/23 at 12:06 AM, but were not completed.
- A head computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) scan was ordered on 01/04/23 at 12:43 AM, but was not completed.
- Staff TT, RN, attempted to perform a SANE exam three times over the course of two hours.
- During the third attempt, Patient #22 stated to Staff TT "get the fuck out bitch! I don't need to talk to you!" He requested to leave. When Staff TT attempted to provide Patient #22 with clothing, he became verbally aggressive. He yelled that he was never seen by a doctor and that nobody had seen him.
- Patient #22 was escorted out to the waiting room on 01/04/23 at 1:40 AM.
- Patient #22 was escorted out of the ED on 01/04/23 at 2:51 AM, by security due to combative behavior.
- His disposition was left without being discharged (LWBD).

2. Review of Patient #25's ED record, showed:
- He was a 29-year-old male, who presented to the ED on 01/10/23 at 3:40 PM, with a chief complaint of weakness, dehydration (a condition caused by excessive loss of water from the body), decreased urine output and "bumps" on his penis that had been present for three days.
- A MSE Note documented by Staff X, Physician Assistant (PA), at 4:19 PM, showed that the patient was triaged, a focused localized MSE was completed.
- Staff X, PA, documented that the patient did not have an EMC and would be referred for care/treatment options.
- Immediately after, Staff C, PA, documented that an EMC existed and had been stabilized prior to transfer/discharge.
- Laboratory blood draws were ordered but none were collected.
- An ED Note completed by Staff Z, ED Technician, at 6:08 PM, showed that the "patient started recording other patients and staff. Patient was asked to not record, as this goes against hospital policy. Patient became very loud and started to curse at staff. Patient was then asked to leave hospital property, patient refused. This tech notified the Charge RN. Security called and escorted patient off hospital property."
- Discharge disposition was documented as LWBD at 6:16 PM.

3. Review of Patient #27's ED record, showed:
- She was a 70-year-old female that presented to the ED on 02/09/23 at 8:48 PM, with a chief complaint of redness, swelling and pain behind the right ear, which started on 02/09/23.
- The patient had a deep brain stimulator (DBS, involves implanting electrodes within certain areas of the brain. These electrodes produce electrical impulses that regulate abnormal deep impulses. The amount of stimulation is controlled by a device placed under the skin in the upper chest and a wire travels under the skin and connects this device to the electrodes in the brain) inserted on 01/09/23 at SSM SLUH for Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors).
- At 8:49 PM, vital signs were blood pressure 149/68, heart rate 70, respiratory rate 18, temperature 98 degrees and oxygen saturation on room air was 99%. No other vital signs were documented for this ED encounter.
- At 9:05 PM, Staff M, PA, documented a MSE note that indicated the patient presented with a postoperative problem. The patient noticed pain, redness, chills that evening; denied drainage. There was redness, warmth and swelling posterior to the right ear. The coronal incision appeared to be healing well.
- Staff M, PA, ordered lab work, blood cultures (a laboratory test to check for bacteria or other germs in a blood sample), a CT of the head and facial bones, and a peripheral venous catheter (a thin, flexible tube that is inserted into a vein in an extremity [i.e., arm, hand, leg or foot]) insertion.
- Ordered lab work was drawn and resulted.
- Staff M, PA documented a completed focused limited exam and noted that further evaluation would be necessary in the ED to determine if an EMC existed.
- At 11:55 PM, Patient #27's visitors became agitated and disruptive in the ED waiting room and were asked to leave the hospital.
- Patient #27 was encouraged by staff and security to stay multiple times, but the patient insisted on leaving with her visitors.
- The ED disposition was LWBD and Left AMA/discontinued care. The ordered CT scans had not been completed.

4. Review of Patient #29's ED record, showed:
- He was a 43-year-old male that presented to the ED on 02/21/23 at 2:41 AM, for irregular feelings in his upper back and chest.
- The patient was triaged and a focused localized MSE was completed by Staff M, PA.
- Vital signs at 2:42 AM were BP 194/94, HR 111, RR 15, Oxygen Saturation 95%. No additional assessment of vital signs were documented after triage.
- An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions), chest x-ray (test that creates pictures of the structures inside the body-particularly bones) and lab work were ordered.
- Staff M, PA, documented that based on the MSE performed and diagnostic tests at this time, further evaluation was indicated and would be performed. The patient was sent to the waiting room.
- The EKG and chest x-ray were completed. The patient refused to have lab work drawn and vital signs taken; he wanted to sleep in the waiting room.
- The patient was asked to leave the ED and was escorted out by security. The ED disposition was LWBD and Left AMA/discontinued care. The ordered lab work had not been completed.

Please see A-2406 for additional information.






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Based on interview, record review and policy review, the hospital failed to provide an appropriate medical screening examination (MSE) within the hospital's capability and capacity for four patients (#22, #25, #27 and #29) of 33 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's ED average monthly census over the past six months was 3,819.

Findings included:

Review of the hospital's policy titled, "EMTALA," revised 02/28/21, showed that any individual presenting to the hospital or dedicated ED, requesting emergency care, received a MSE to determine the presence of an EMC. A MSE was defined as an examination which is sufficiently detailed to reveal whether the patient suffers from an EMC and must include medical indicated screens, tests, mental status evaluations, history and physical examinations, etc. The MSE must be provided within the capability of the hospital's ED. Triage alone is not a MSE. An individual has the right to refuse a MSE.

1. Review of Patient #22's Ambulance record, dated 01/03/23 at 11:06 PM, showed the following:
- Patient #22 was a 22-year-old transgender (denoting or relating to a person whose gender identity does not correspond with the sex registered for them at birth) male to female found lying in the bushes. He stated he was drinking and was sexually assaulted (sexual contact or behavior that occurs without consent of the victim) with anal penetration.
- He was choked and hit. He denied drug use. He was stumbling around, his speech was slurred, and he stated several times he wanted to die.
- Documentation showed he was oriented to self, place, time, and event, and was agitated, combative and confused. He had right knee pain and a right knee abrasion.

Review of Patient #22's ED record showed:
- He was a 22-year-old male who presented to the ED on 01/03/23 at 10:55 PM, with a chief complaint of sexual assault.
- Past medical history included depression (extreme sadness that doesn't go away), human immunodeficiency virus (HIV, virus that attacks the cells that help the body fight infection), a learning disability, and SI. The charge nurse was notified of the need for a sexual assault nurse examiner (SANE, a RN or nurse practitioner who has completed specialized training to assist sexual assault victims and collect all forensic evidence and perform exams) evaluation.
- Several laboratory tests were ordered on 01/04/23 at 12:06 AM, but were not completed.
- A head computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) scan was ordered on 01/04/23 at 12:43 AM, but was not completed.
- Staff TT, RN, attempted to perform a SANE exam three times over the course of two hours.
- During the third attempt, Patient #22 stated to Staff TT "get the fuck out bitch! I don't need to talk to you!" He requested to leave. When Staff TT attempted to provide Patient #22 with clothing, he became verbally aggressive. He yelled that he was never seen by a doctor and that nobody had seen him.
- Patient #22 was escorted out to the waiting room on 01/04/23 at 1:40 AM.
- Patient #22 was escorted out of the ED on 01/04/23 at 2:51 AM, by security due to combative behavior.
- An ED Provider Note showed that Staff SS, Physician, was not notified of Patient #22's behavior and did not have the opportunity to evaluate him prior to him leaving the ED.
- His disposition was left without being discharged (LWBD).

During a telephone interview on 03/02/23 at 8:45 AM, Staff SS, Physician, stated that if a patient came in with a chief complaint of sexual assault, the SANE nurse would examine the patient first and then the physician would address other medical needs afterward. Some patients would decline the SANE exam or SANE kit. If a patient declined the SANE exam, then the physician would address the complaints not related to the sexual assault. Staff SS stated that Patient #22 had been involved in a motor vehicle crash earlier in the day so she ordered labs and a head CT. She was not notified that Patient #22 had become aggressive and was escorted from the hospital.

During a telephone interview on 03/02/23 at 9:15 AM, Staff TT, SANE RN, stated that any patient who refused care and refused to allow staff in the room was treated as leaving against medical advice (AMA). Patients who reported sexual assaults would have the SANE exam before being examined, and having their MSE, by a physician, unless the patient needed to be medically stabilized first. Patient #22 had no medical complaints other than the sexual assault. He would not come out from under the covers and would not speak to her. She approached him three different times attempting to start the SANE exam/interview. The third time she approached him, he got out up and told her that he was going to punch her. She reported that she got the attending physician, Staff SS, Physician, to talk with the patient. He then became aggressive with staff, started punching at people and spit at another nurse. Due to Patient #22's behavior he was escorted from the hospital.

2. Review of Patient #25's ED record showed:
- He was a 29-year-old male, who presented to the ED on 01/10/23 at 3:40 PM, with a chief complaint of weakness, dehydration (a condition caused by excessive loss of water from the body), decreased urine output and "bumps" on his penis that had been present for three days.
- A MSE Note documented by Staff X, Physician Assistant (PA), at 4:19 PM, showed that the patient was triaged, a focused localized MSE was completed.
- Staff X, PA, documented that the patient did not have an EMC and would be referred for care/treatment options.
- Immediately after, Staff C, PA, documented that an EMC existed and had been stabilized prior to transfer/discharge.
- Laboratory blood draws were ordered but none were collected.
- An ED Note completed by Staff Z, ED Technician, at 6:08 PM, showed that the "patient started recording other patients and staff. Patient was asked to not record, as this goes against hospital policy. Patient became very loud and started to curse at staff. Patient was then asked to leave hospital property, patient refused. This tech notified the Charge RN. Security called and escorted patient off hospital property."
- Discharge disposition was documented as LWBD at 6:16 PM.

During a telephone interview on 02/28/23 at 2:30 PM, Staff X, PA, stated that he performed a focused exam and ordered initial labs for on Patient #25. He stated that focused exams, were not a complete MSEs, but would determine if an EMC existed. It was determined through that focused exam that Patient #25 had no EMC. When Patient #25 returned to the waiting room he became loud and aggressive after being asked to not take video recordings of other patients and was asked to leave hospital property.

During a telephone interview on 03/01/23 at 9:00 AM, Staff Z, ED Technician, stated that Patient #25 started recording an incident with another patient. When he was told that recording in patient care areas was prohibited he became verbally aggressive and security escorted him from the building. A medical staff provider had to ensure that a patient did not have an EMC before a patient could be escorted from the property.

During a telephone interview on 03/01/23 at 9:55 AM, Staff EE, Charge RN, stated that she could not specifically remember Patient #25 as she got calls to the waiting room for disruptive patients "at least a couple of times a day." Prior to a patient being asked to leave hospital property, the Charge RN had to ensure that the patient had been received a MSE by a qualified provider, and did not have an EMC.

During a telephone interview on 02/28/23 at 2:00 PM, Staff F, ED Nursing Director, stated that during the MSE process some patients would see and Advanced Practice Provider (APP) and some patients would see both an APP and an ED attending physician, depending on their level of acuity and what treatment was need. A LWBD disposition meant that a patient had been evaluated by an APP or a physician and had care started but decided to leave before care was completed. Patient #25 was marked as LWBD as his MSE had been completed.

Review of Patient #25's ED record, from Hospital C, showed:
- He presented to Hospital C's ED on 01/11/23 at 8:02 PM, with a chief complaint of flu-like symptoms for two weeks and a painful lesion on penis for the past week.
- An ED Provider note, completed by a PA, showed that Patient #25 had a past medical history of un-medication HIV and syphilis.
- It was documented that the patient was at SSM SLUH hospital earlier but left AMA due to long wait times.
- Several laboratory test were ordered and completed.
- His syphilis results were reactive. The patient requested treatment and prophylaxis (to prevent disease) and was given two antibiotic injections. He was also provided a prescription for an oral antibiotic.
- He was discharged on 01/11/23 at 4:58 AM.

3. Review of Patient #27's ED record showed:
- She was a 70-year-old female that presented to the ED on 02/09/23 at 8:48 PM, with a chief complaint of redness, swelling and pain behind the right ear, which started on 02/09/23.
- The patient had a deep brain stimulator (DBS, involves implanting electrodes within certain areas of the brain. These electrodes produce electrical impulses that regulate abnormal deep impulses. The amount of stimulation is controlled by a device placed under the skin in the upper chest and a wire travels under the skin and connects this device to the electrodes in the brain) inserted on 01/09/23 at SSM SLUH, secondary to Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).
- The patient was alert and oriented to person, place, time and situation. At 8:49 PM, the patient's vital signs was a temperature of 98 degrees, blood pressure was 149/68, heart rate of 70, respirations 18 and oxygen saturation on room air was 99%. No other vital signs were documented for this ED encounter.
- At 9:05 PM, Staff M, PA, documented a MSE note that indicated the patient presented with a postoperative problem from the DBS insertion on 01/09/23. The patient noticed pain, redness, chills that evening; denied drainage. There was redness, warmth and swelling posterior to the right ear. The coronal incision appeared to be healing well. It was documented that a focused limited exam had been completed and further evaluation would be necessary in the ED to determine if an EMC existed.
- Several laboratory blood draws to check for infection were ordered. Lab work revealed a high c-reactive protein (CRP, a blood test that measures the level of CRP in the blood; the liver releases more CRP in the blood if inflammation is present in the body) of 1.0 (normal range was less than 0.5 mg/dl).
- A CT of the head and facial bones was ordered by Staff M, but never completed.
- At 11:55 PM, Patient #27's visitors became agitated and disruptive in the ED waiting room and were asked to leave the hospital.
- Patient #27 was encouraged by staff and security to stay multiple times, but the patient insisted on leaving with her visitors.
- The ED disposition was LWBD and Left AMA/discontinued care. The ordered CT scans had not been completed.

During a telephone interview on 03/01/23 at 7:05 AM, Staff S, RN, stated that an attending physician was to come out with in five minutes if a patient was escalating in the ED waiting room. The physician would have to ensure that a MSE had been completed to determine if the patient was medically stable to leave. She did not know if this occurred with Patient #27 before she left.

During a telephone interview on 02/28/23 at 11:20 AM, Staff L, Charge RN, stated that the waiting room was fairly full the night of 02/09/23. Staff S, RN, notified her that patient #27's visitors were escalating, making threats and needed to be removed. A new ED protocol was recently started that a Charge RN must go out and assess the situation when visitors/patients become disruptive in the waiting room. If a patient needed to be removed from the ED, a provider was notified to come and assess the patient. When she arrived to the waiting room, Security had been contacted to remove Patient #27's visitors. Patient #27 was not asked to leave, but said she would go with her daughter and requested that her intravenous (IV, in the vein) catheter be removed. The patient left before a provider came out to assess the patient. Staff L stated she reviewed Patient #27's medical record and called the patient to let her know that staff did not ask her to leave and encouraged her to come back to finish being evaluated. She stated she was concerned about the patient's age and possible postoperative issue that may have warranted a potential admission.

During a telephone interview on 02/28/23 at 1:00 PM and 03/6/23 at 11:15 AM, Staff M, PA, stated that her only contact with Patient #27 was when she did a MSE on the patient in the triage room. She looked behind the patient's ear and at the incision site, did a brief chart review and placed orders. She ordered lab work based on the patient's complaints and Staff P's concern about a possible postoperative infection. She ordered a CT of the facial bones to assess if the patient had a collection of infection or any abscesses. If the patient had stayed to be evaluated, she suspected the patient would have had a neurosurgery consult and been admitted to the hospital. When a patient in the waiting room was being disruptive and was asked to leave, or a patient wanted to leave AMA or LWBD, an ED provider was asked to see the patient to try and de-escalate the situation, discuss the risks and benefits and assess the patient to determine if an EMC existed. She probably would not have been able to determine if a patient had an EMC unless all the patient's lab work and other ordered tests were completed.

Review of Patient #27's Hospital B Medical Record showed:
- Patient #27 contacted her surgeon's office on 02/10/23, and was instructed to go to Hospital B's ED to be evaluated, and if necessary, the hospital would arrange a direct admit to SSM SLUH.
- She arrived to Hospital B's ED on 02/10/23 at 1:30 PM, with a chief complaint of infection to a surgical site behind her right ear. She had pain and swelling, redness and warmth over her right head, right neck and right upper chest that began 02/09/23. The pain was centered behind the right ear, at the site of recent surgery placement of a DBS. She also had an incision in the right anterior chest with redness and tenderness just below the right collarbone.
- The patient appeared to have cellulitis (infection of the skin) overlying the recent surgical sites; the distribution was suspiciously consistent with the surgical sites covering two of the three incisions. This raised the possibility that the hardware inside the patient's body could be involved.
- The patient stated she went to SSM SLUH on 02/09/23, and left because it was "a shit show," stating they would not allow her family or visitors to be with her in the ED.
- Lab work and blood cultures were drawn at Hospital B. Patient #27 was transferred by ambulance on 02/10/23 at 10:48 PM, to SSM SLUH with a diagnosis of postoperative wound cellulitis.

Review of Patient #27's SSM SLUH 02/10/23 medical record showed that she was admitted and had surgery on 02/13/23 for removal of an infected right DBS lead extension.

4. Review of Patient #29's ED record showed:
- He was a 43-year-old male that presented to the ED on 02/21/23 at 2:41 AM, for irregular feelings in his upper back and chest that had been present for three months. He had intermittent shortness of breath. The patient denied a history of cardiac disease or recent injury.
- The patient's vital signs at 2:42 AM were an elevated BP of 194/94 (normal was approximately 90/60 to 120/80), HR 111, RR 15, Oxygen Saturation 95%. No additional assessment of vital signs were documented after triage.
- Staff M, PA, documented that a focused localized MSE was completed and that based on the MSE, further evaluation was indicated and would be performed. The patient was sent to the waiting room.
- An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) and chest x-ray (test that creates pictures of the structures inside the body-particularly bones) were ordered. The EKG showed a normal rhythm with incomplete right bundle branch block (when electrical signals in the heart become blocked and may cause an irregular heartbeat), borderline EKG.
- Laboratory blood work was ordered but never collected.
- The patient refused to have lab work drawn and vital signs taken; he wanted to sleep in the waiting room.
- At 8:27 AM, Staff N, PA, spoke with the patient and documented the patient refused all care and became aggressive with staff when asked to get vital signs and lab work; he wanted to sleep only. The patient denied SI/HI/Self Harm and was alert and oriented. At this time, no medical emergency existed.
- Due to the patient's refusal of care, he was escorted out of the ED.
- The ED disposition at 8:48 AM, was LWBD and Left AMA/discontinued care. The ordered lab work had not been completed.

During a telephone interview on 02/28/23 at 1:00 PM, Staff M, PA, stated that she worked 6:00 PM to 6:00 AM and she saw Patient #29 when he arrived to the ED. She did not remember much about him, but thought she did a chest pain workup. She was not asked to see Patient #29 for further evaluation after her initial contact with him. She would not be able to determine if the patient had an EMC until his lab work was completed to see if his troponin was elevated or had an electrolyte abnormality.

During a telephone interview on 02/28/23, Staff N, PA, stated he worked 6:00 AM to 6:00 PM and stated Patient #29 had already been checked in when he arrived to work. It was reported to him that the patient was sleeping in the waiting room and refused to have vital signs checked and lab work drawn. Staff N and a triage RN went to the waiting room and spoke with the patient and gave him the option to get lab drawn and workup completed or he would have to leave. The patient was not SI/HI and was alert and oriented. The patient was not cooperative and just wanted to go back to sleep. Staff N could not completely rule out any type of medical condition, as there was no lab work completed, but no obvious medical emergency existed with Patient #29. The patient was escorted out of the waiting room by security.

During a telephone interview on 03/02/23 at 10:30 AM, Staff F, RN, ED Director, stated that the removal of individuals from the ED for safety reasons was started about a month prior. If a patient in the ED waiting room was becoming disruptive and required removal for safety reasons, the ED staff would notify the ED Charge RN and security. De-escalation of the situation would be attempted first, and if the situation was not resolved, the ED charge nurse would have a provider assess the patient to ensure an EMC did not exist prior to the patient being removed from the hospital.

During a telephone interview on 03/01/23 at 9:55 AM, Staff K, ED Medical Director, stated that a MSE consisted of a brief history and physical, a physical examination, orders for laboratory or imaging based on presentation. He stated that labs or tests were not always required to determine if a patient had an EMC. He stated that a UDS was not always helpful because it would not tell, when or how much of the drug was ingested, only that the drug was ingested. He stated that MSEs were completed by a provider in the intake area either after, or in conjunction, with the nursing triage process. He defined an appropriate MSE as "an evaluation using clinical judgement and discretion of the provider performing the exam." Staff K went on and explained for behavioral health patients with hallucination, that at times these hallucinations were caused by drugs, therefore a MHE would not be required. He stated that behaviors that could result in a person's removal from the ED would be any threatening behavior. When a behavioral issue was reported to nursing or medical staff, a provider would come assess the situation and see if the behavior was truly a behavioral issue or if it was possibly related to a psychiatric or medical condition that precluded them from acting in a normal manner. The provider would look at contributing factors and the physiological complaint prior to concluding that there was no EMC that prevented them from being asked to leave.


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