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Based on interview and document review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to obtain a Medical Screening Exam (MSE)for 1 (Patient #1) of 20 patients reviewed for a MSE, resulting in the potential for less than optimal outcomes for all patients seeking emergent care. Findings include:

1. The failure to obtain Medical Screen Examp. (See tag 2406)

Based on interview and document review, the facility failed to provide a medical screening exam (MSE) for 1 (Patient #1) of 20 patients reviewed for a MSE, resulting in the potential for less than optimal outcomes to all patients seeking emergency care at the facility. Findings include:


During record review on 03/21/2023 at 1510 of Patient (pt) #1's Emergency Department (ED) documentation dated 09/26/22, revealed the following:

09/26/22 at 0721: Pt #1 arrived at ED.
09/26/22 at 0725: Triaged as "Acuity 3 (urgent). Vitals were not recorded due to patient's refusal.
09/26/22 at 0728: Physician orders for urine drug screen and blood chemistries.
09/26/22 at 0745: Discharged. (24 minutes)
09/26/22 at 0745: Nursing note by ED staff H revealed "Patient hitting glass window and continues yelling at sheriff's deputies. Pt. taken off unit to jail in custody of police."

There was no documentaiton in the patient's chart reflecting a Medical Screening Exam (MSE).

Review of 'ED Triage Notes' dated 09/26/22 at 0746 authored by primary caregiver, ED RN (Staff I) revealed "The patient arrived to the ED in handcuffs via 2 county sheriff officers. Pt. is refusing at this time to cooperate with nursing staff. The officer states that the patient's wife called 911 this morning because she was concerned that she (Pt.#1) was going to harm herself. The officer stated that the spouse said, "she was going to run her car into the Shell gas station." She also told the police officer "I want to kill myself, why don't you just let me." The pt. states that she wants to kill herself but won't actually do it because she has kids. The pt. is in room yelling that she needs to leave because she has court at 8 am. Pt. yelling that she needs to leave right now and saying we are holding her against her will. Pt. refusing vitals taken at this time. Pt. also refusing to answer questions pertaining to her health history."

On 03/22/23 at 0929, an interview was conducted with ED RN Staff H. Staff H was asked to clarify his nursing note and the timing of events. Staff H stated, "(Staff I) was the primary nurse. I was never in the room with the patient. I overheard screaming. One officer stayed with the patient and the other was at the nurse's desk, providing information, I think. I did not speak with PD (police department), but PD heard the threats. She recanted her statements. She wanted to leave for court. After she recanted, they (police) stated she was under arrest for assaulting police and left. The doc had not arrived. (Staff I) called doc to let him know the patient left." Staff H was asked if anyone attempted to contact the officers and have the patient return. Staff H stated, "I don't know, but she was safe with the officers."

A telephone interview was conducted with primary RN Staff I at 0939 on 03/22/23. Staff I stated "She was brought by police for suicidal ideation but had court that morning ... she told her girlfriend that she wanted to crash her car into the gas station. Girlfriend called PD; she was brought in combative. She wouldn't answer questions and wanted to get to court. We attempted de-escalation, and she wanted her girlfriend present. They fought once she came back. She refused questions and vital signs still. I stepped out to use the restroom, when I came out, the officers had her back in cuffs and walked out. I asked Staff C and Staff H, and they said, "She's going to jail." The physician was sitting at the nurse's desk." Staff I was questioned if anyone attempted to stop the officers and inquire why they are leaving. Staff I stated, "I'm not sure, they were already out the door."

On 03/22/23 at approximately 1000, an interview was conducted with ED RN Staff C. Staff C was asked to relate her recollection of events. Staff C stated, "Pt.#1 was here, threatened to crash her car into a gas station. PD (police) declined to 'pitt and cert' (petition the patient; certify the patient). PD requested medications be given, I said 'I can't until doc sees her.' The officers next removed the patient, after she began slamming her fists on the glass." Staff C was next queried if Pt.#1 received a medical screening exam (MSE). Staff C stated, "We did not send the patient out, PD took her. No MSE."

On 03/22/23 at 1203, an interview was conducted with ED treating physician Staff L. Staff L was questioned what a medical screening exam (MSE) consisted of. Staff L stated, "Physical examination, labs. Medical clearance." Staff L was asked if Pt.#1 received an MSE? Staff L stated, "As soon as she was seen. She did receive an MSE by me, I observed her for 3-5 minutes, across the room." Staff L was questioned if observing a patient was sufficient for an MSE. Staff L stated, "She has had enough screening done in our system. She refused all care. I saw her for 3-5 minutes. She was AMA (against medical advice), refused labs, and questions. I came to the nurse's desk; the room is directly across from it. I could see her through the glass walls. She came out to the desk demanding to leave." Staff L was next queried regarding his provider note stating "pt. taken away before I saw the patient." Staff L again stated, "I saw her across the room." Staff L was asked if he attempted to contact the officers either before or after they left? Staff L stated, "No reason to contact. I was satisfied with the MSE." Staff L was asked to recall the behaviors he observed over the 3-5 minutes. Staff L stated, "Pacing, shouting, very focused about what she didn't want." Staff L was questioned if police had ever removed a patient from his care before. Staff L stated, "No. I went back to the call room, and they just left." Staff L was next asked if he was concerned that Pt.#1 could have an emergency medical condition (EMC)? Staff L stated, "No, except the psyche condition." Staff L was next questioned why Pt.#1 was 'dispositioned' as AMA (against medical advice) and, what medical advice was provided to the patient? Staff L stated, "Pt. was advised to let us assess her vital signs, obtain her complaint and answer questions. She refused all advice."

On 03/24/23 at 1340 police officer Staff K returned a phone call request for an interview. We took her into protective custody, she was not under arrest. She was a danger to herself. She escalated at the ER. She slammed her hands on the glass wall. A nurse said "OUT!" and motioned with her hand, pointing for us to go to the door." Staff K was asked if he knew who the order was directed at. Staff K stated, we were the only ones there, I think. She was looking directly at us and motioned for us to leave. It was clearly meant for us to leave." Staff K did not know who the 'lady behind the counter' was. Staff K was asked if he saw the physician and if there was any interaction between the physician and the patient? Staff K stated, "He didn't talk to us. He was in proximity, about 10 feet away, directly in front of us, sitting at the desk. He did not examine the patient. The last straw was when she was sitting in the chair and slammed the window. Nobody tried to stop us. We heard 'Get out!' Staff K was asked if physician Staff L was present when the officers left? Staff K stated, "He had been charting and wasn't fazed."

Review of Policy titled "Emergency Medical Treatment and Labor Act (EMTALA)" dated 6/27/2008 states "If an individual or legal representative on behalf of the individual refuses to allow a MSE, including the refusal of any ancillary services conducted during the examination or treatment, the follow shall occur:
-The physician shall attempt to determine the individual's decisional capacity to refuse a medical screening examination.
-The physician shall inform the individual (or legal representative) of the hospital's obligation to perform a MSE, the benefits of the examination, and the significant known risks of refusing such examination.
-If the individual is determined to have the capacity to make informed decisions and thus able to decide to refuse the examination, the individual will be requested to sign the Release of Liability Patient Leaving Against Medical Advice Form. If the individual refuses to sign the form, this shall be documented on the form and placed in the medical record. The individual shall be invited to return at any time.
-If the individual is determined to be incapacitated and unable to make decisions to refuse the examination, the hospital shall detain the individual until a medical screening examination has been performed.
-A description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual shall be documented in the medical record."