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Based on record review and interview, the hospital failed to ensure compliance with the requirements of CFR 489.24 as evidenced by:

1. Failing to ensure an appropriate MSE (Medical Screening Examination) was performed on a patient who presented to the hospital's emergency department in order to determine if a medical and/or psychiatric emergency medical condition existed for 1 of 20 sampled patients (Patient #1). (See A-2406)

2. Failing to ensure for the appropriate discharge of a patient who had an EMC (Emergency Medical Condition) that had not been stabilized for 1 of 20 sampled patients (Patient #1). (See A-2409)

Based on record review and interview, the hospital failed to ensure an appropriate MSE (Medical Screening Examination) was performed on a patient who presented to the hospital's emergency department in order to determine if a medical and/or psychiatric emergency medical condition existed for 1 of 20 sampled patients (Patient #1). Findings:Patient #1: Medical record review on 10/03/16 revealed Patient #1 presented to the hospital's ED via ambulance on 09/14/16 at 7:39 p.m. Documentation on the Prehospital Care Report Summary revealed an admitting complaint of Psychiatric/Suicidal attempt. Review of the demographics sheet revealed an admit complaint of Suicidal, and a previous admit of 09/11/16 (3 days earlier). Documentation revealed Patient #1 was triaged at 8:27 p.m. by S6RN with a chief complaint of abdominal pain and nausea. The patient's vital signs were documented as B/P- 106/74, Pulse- 114, RR- 20, O2 sat- 94%, T- 98.3, and pain level 7/10. History states arrived by EMS. Documentation on the Self-Harm Assessment performed by S6RN revealed Patient #1 answered "no" to questions - have you recently felt down, depressed, hopeless, lost interest or pleasure in doing things, thoughts of harming or killing yourself.Documentation on the Nursing Progress Note dated 09/14/16 at 9:04 p.m. (documented by S6RN) revealed "patient would not stay in his bed for evaluation; continued to go outside, go to restroom, roaming around ED, patient removed from ED by security". Documentation revealed Patient #1 was uncooperative and left the ED without being seen by a physician. A discharge time of 9:04 p.m. was documented and documentation revealed the patient left ambulatory and the charge nurse was notified. Interview on 10/03/16 at 4:10 p.m. with S3RN confirmed that there was no other documentation for Patient #1's behavior or condition that led to him being escorted from the ED on 09/14/16. She further confirmed that the patient had not been seen by a physician or mid-level staff for a medical screening examination. S3RN reported that S6RN was the Charge Nurse on duty when Patient #1 presented to the ED. On 10/04/16 attempts were made to interview S6RN by phone at 9:50 a.m., 10:15 a.m., 11:30 a.m., 2:00 p.m., and 4:30 p.m. that were unsuccessful. According to interview with S1CNO on 10/04/16 at 4:30 p.m. S6RN had been suspended on 10/03/16 for 3 days because of the incident.Interview on 10/04/16 at 3:05 p.m. with S4Security revealed that he was not the security officer in the ED and did not have any interaction with Patient #1. He stated that he was making rounds in the hospital when he was notified by S5Security who was assigned to the ED during the incident and was notified by him to contact LCPD because Patient #1 would not leave the grounds.On 10/04/16 attempts were made to interview S5Security by phone at 3:30 p.m., 4:00 p.m., and 4:20 p.m. that were unsuccessful. S2RM on 10/04/16 at 4:40 p.m. confirmed with the Human Resources department that the surveyor had the most recent contact numbers for S6RN and S5Security officer. In a phone interview on 10/13/16 at 11:05 a.m., S1CNO stated she was first made aware of the incident involving Patient #1 on Friday, 9/30/16. S1CNO indicated that she had met with S6RN to discuss the incident involving Patient #1 and a decision was made to suspend S6RN for failing to comply with departmental and job expectations concerning documentation in the patient's medical record. S1CNO reported that usually all incidents involving EMTALA concerns resulted in a suspension if felt warranted by Administration. S1CNO further reported that she reviewed Patient #1's medical record again after surveyors left the hospital and was planning to terminate S6RN, but after meeting with the CEO it was decided not to terminate S6RN but to write an incident in her personnel file. S1CNO reported that she met with S6RN a second time on Friday, 10/7/16 and during this meeting S6RN decided to resign from the hospital.

When asked if she (S1CNO) had spoken with S6RN about details involving Patient #1's visit to the ED on 09/14/16, S1CNO indicated that she had. S1CNO indicated that S6RN reported the following in regards to Patient #1: S6RN reported Patient #1 was frequently in the ED for abdominal pain and problems and that he was there in the ED just a few days prior to 09/14/16. S6RN reported the ED was very busy that night and she (S6RN) just never looked at the ambulance face sheet or documentation to see Patient #1 had issues with psychiatric problems or suicidal ideations. S6RN reported Patient #1 was always in there with abdominal pain and he had told her that night he was having abdominal pain. S6RN reported being unaware of any psychiatric or suicidal issues with Patient #1. S6RN reported that after Patient #1 was triaged before he was seen by a mid-level practitioner or physician that he kept getting up off of the stretcher and going outside to smoke and going to the bathroom and would not stay in the room or on the stretcher to be seen. S6RN reported that when she asked Patient #1 to stay in his room he became increasingly verbally abusive to ED staff and told her he was refusing treatment and left the ED and went outside to smoke. S6RN reported it was then that she (S6RN) called for hospital security to accompany Patient #1 while he was outside. S6RN reported that Patient #1 did not want to stay and be seen in the ED. S6RN reported that she did not know why she had not charted more details other than she was just extremely busy that night. When asked if she (S1CNO) had spoken with the security officer involved. S1CNO indicated that she had. S1CNO reported that she had talked with S5Security but could not determine who actually said the patient could not come back in the ED and that security was just told by the nurse to stay with the patient until the police arrived.

In a phone interview on 10/13/16 at 6:40 p.m., S5Security reported that he remembers the incident on 09/14/16 involving Patient #1. S5Security reported Patient #1 comes to the ED frequently and always causes problems. S5Security further stated that he was not assigned to the ED that night but was assisting in training a new guy when he went to the ED and saw Patient #1. S5Security reported Patient #1 was always really loud and usually became verbally abusive to ED staff. S5Security reported that on this particular night Patient #1 was up walking around and the nurses were trying to keep him in his room on the stretcher. S5Security reported Patient #1 kept going outside and smoking and would not come back in when the nurse would try to get him to return to his room and that's when he started to become very loud and verbally abusive to the ED staff and would then go back outside. S5Security reported the charge nurse (S6RN) kept trying to get him to stay in the ED. S5Security reported Patient #1 eventually got his belongings and went outside of the ED by the ambulance entrance. S5Security reported S6RN told him Patient #1 had to leave because he would not stay in his room and that was why he (S5Security) was standing outside with Patient #1 when the police arrived. S5Security further stated that Patient #1 was sitting and stumbling around the ambulance entrance and would not leave the hospital grounds and that he (S5Security) stayed with the patient until the police arrived for the patient's safety. The surveyor asked who had made the decision to call the police and S5Security stated that another security guard had decided to call the police because he (S5Security) could not stay with the patient all night outside the ED to keep him from stumbling into the street into traffic and/or injuring himself. S5Security further stated that this was not the only time police had to come escort the patient from the hospital property because of his violent abusive behaviors. S5Security stated Patient #1 would not follow directions and leave the property so in the best safety of the patient the police were called. S5Security indicated the police arrived and the police officer talked with Patient #1 and then went into the ED to speak with the charge nurse while he (S5Security) remained outside with Patient #1. The police officer returned and then called an ambulance to pick up Patient #1.

Interview on 10/04/16 at 11:20 a.m. with S9LCPD/Captain revealed to surveyors that Patient #1 was well known to the Police Department and had a history of narcotics abuse and attempts of overdosing on pills. S9LCPD/Captain indicated that on 09/14/16 at approximately 6:52 p.m. was when the first contact was made with Patient #1. Patient #1 had a vehicle accident and drove a car into a utility pole and had fled the scene and was later apprehended by the police a few blocks away. During that encounter Patient #1 told the officers that he had taken a bunch of pills and wanted to harm himself that was how Patient #1 ended up at the ED at hospital (a). The officer on site had called for an ambulance to transport Patient #1 to the hospital and followed the patient to the ED. S9LCPD/Captain further stated that there are usually no written reports documented on these types of encounters, but after the LCPD was called back to the hospital (a) ED the second time he had made some unofficial documented notes of the evening's incident. He stated that S4Security had called for LCPD for the same person for behavior problems and S4Security had stated that Patient #1 could not re-enter the hospital. S9LCPD/Captain stated that there was A/V from the officers shoulder cam that the surveyors could view. Surveyor viewed A/V from 09/14/16 of the police officer arriving to hospital (a) where Patient #1 was sitting on a bench on hospital (a) grounds with a hospital (a) Security staff standing by the patient. Patient #1 stood and fell to the ground during verbal questioning by the police officer. S9LCPD/Captain stated that the police officer onsite called the ambulance to transport Patient #1 to hospital (b) ED.Review of the 2nd ambulance Prehospital Care Report Summary dated 09/14/16 revealed Patient #1 was picked up at hospital (a) at 9:42 p.m. and transported to hospital (b) at 10:02 p.m. The Chief complaint was listed as Suicidal Ideations, Behavioral Disorder, Psychiatric Emergency, and Overdose. Documentation revealed Patient #1's vital signs were as follows: B/P-136/95, P-128, R-16, pupils constricted. A narrative history documented by the ambulance paramedic revealed: "Upon arrival patient #1 was lying on the grass at the hospital parking lot with LCPD officer and unit 400 shift supervisor on scene. Per LCPD officer patient #1 was taken to the hospital ED for Suicidal Ideations and ingesting a hand full of Ambien. Per LCPD officer patient #1 was handcuffed by LCPD and transported by ambulance just prior to this incident. Per LCPD officer patient #1 was non-compliant with hospital ED staff, so they had security escort him out of the ED with his belongings and he was called. Therefore he (LCPD officer) called for an ambulance to have him taken to hospital (b) because the hospital ED said they did not want him back in the ED even though he was still on their property. Patient #1 was loaded and taken to hospital (b) ED for evaluation."

Review of the Emergency Provider Record dated 09/14/16 at hospital (b) revealed Patient #1 presented to the ED confused, lethargic, and unresponsive. Vital signs were documented as B/P-190/159, Pulse-122. Documentation revealed Patient #1 was intubated by the ED physician and placed on Mechanical Ventilation and admitted to the ICU unit.

Based on record review and interview, the hospital failed to ensure for the appropriate discharge of a patient who had an EMC (Emergency Medical Condition) that had not been stabilized for 1 of 20 sampled patients (Patient #1). Findings:
Patient #1: Medical record review on 10/03/16 revealed Patient #1 presented to the hospital's ED via ambulance on 09/14/16 at 7:39 p.m. Documentation on the Prehospital Care Report Summary revealed an admitting complaint of Psychiatric/Suicidal attempt. Review of the demographics sheet revealed an admit complaint of Suicidal, and a previous admit of 09/11/16 (3 days earlier). Documentation revealed Patient #1 was triaged at 8:27 p.m. by S6RN with a chief complaint of abdominal pain and nausea. The patient's vital signs were documented as B/P- 106/74, Pulse- 114, RR- 20, O2 sat- 94%, T- 98.3, and pain level 7/10. History states arrived by EMS. Documentation on the Self-Harm Assessment performed by S6RN revealed Patient #1 answered "no" to questions - have you recently felt down, depressed, hopeless, lost interest or pleasure in doing things, thoughts of harming or killing yourself.Documentation on the Nursing Progress Note dated 09/14/16 at 9:04 p.m. (documented by S6RN) revealed "patient would not stay in his bed for evaluation; continued to go outside, go to restroom, roaming around ED, patient removed from ED by security". Documentation revealed Patient #1 was uncooperative and left the ED without being seen by a physician. A discharge time of 9:04 p.m. was documented and documentation revealed the patient left ambulatory and the charge nurse was notified.
Interview on 10/04/16 at 2:00 p.m. with S7Physician revealed all of the ED Medical Staff attend EMTALA training annually. Surveyor questioned if S7Physician was aware of the incident that occurred with patient #1 on 09/14/16 and he replied he received a phone call from nursing administration last Thursday (9/29/16) regarding the patient and a possible EMTALA violation. The patient presented to the ED and was not evaluated by either a mid-Level practitioner or a physician, only the registered nurse. Patient #1 was brought to a room inside of the ED where he became belligerent, verbally abuse, and refusing to stay in the ED room. Patient #1 was then let go from the ED by S6RN. S7Physician stated when nursing administration reviewed the incident, the RN was suspended. Interview on 10/03/16 at 4:10 p.m. with S3RN confirmed that there was no other documentation for patient #1's behavior or condition that led to him being escorted from the ED on 09/14/16. She further confirmed that the patient had not been seen by a physician or mid-level staff for a screening.Interview on 10/04/16 at 4:05 p.m. with S1CNO stated that she had spoken to S6RN yesterday when she was called in for disciplinary actions. S1CNO further explained that the hospital had just learned of the incident a few days ago and was still investigating the incident. S1CNO stated that she took S6RN statement of the occurrence and was told that patient #1 had become very abusive acting toward ED staff and refused to stay in his room and be treated. Because of the patients actions he was escorted from the ED by hospital Security and was not allowed to return. S1CNO stated that there was no documentation in the patient #1's record to support the nurse's statement. S1CNO further stated that S6RN also told her that the ED was familiar with the patient and she had stated that in investigating incident had learned that the patient #1 had come in several times and was in the ED on 09/11/16 just prior to this incident for abdominal pain and had full GI workups done. S1CNO stated that she could not comment on why on this occasion that the chief complaint was abdominal pain but listed on the ambulance sheet as Suicidal/Psychiatric and the hospital demographic sheet as well.Review of the statement dated 10/03/16 by S6RN revealed patient #1 was removed from the emergency room after refusing medical treatment. He did not want to wait to be seen and would not stay in his room. He was escorted off the premises by security which is our policy when a patient refuses medical treatment.On 10/04/16 attempts were made to interview S6RN by phone at 9:50 a.m., 10:15 a.m., 11:30 a.m., 2:00 p.m., and 4:30 p.m. that were unsuccessful. According to interview with S1CNO on 10/04/16 at 4:30 p.m. S6RN had been suspended on 10/03/16 for 3 days because of the incident.Interview on 10/04/16 at 3:05 p.m. with S4Security officer revealed that he was not the security officer in the ED and did not have any interaction with the patient. He stated that he was making rounds in the hospital when he was notified by S5Security officer who was assigned to the ED during the incident and was notified by him to contact LCPD because patient #1 would not leave the grounds.On 10/04/16 attempts were made to interview S5Security officer by phone at 3:30 p.m., 4:00 p.m., and 4:20 p.m. that were unsuccessful. S2RM on 10/04/16 at 4:40 p.m. confirmed with the Human Resources department that the surveyor had the most recent contact numbers for S6RN and S5Security officer. Review of the hospital policy titled Discharge of Patients, revised April 2016: 5. If a patient leaves the ED of their own choice without notifying any of the ED staff, it should be documented in the EMR as either a LWBS (Left without being seen) or LBTC (Left Before Treatment Complete). ED staff should first attempt to locate the patient. If confirmed that patient has left the ED, RN should communicate with the ED charge nurse, security, and ED patient access. Further review of the policy revealed there was no part directing ED staff to have security escort patients refusing treatment from the ED and premises. S1CNO confirmed that the policy reviewed was the policy S6RN had referred to. In a phone interview on 10/13/16 at 11:05 a.m., S1CNO stated she was first made aware of the incident involving Patient #1 on Friday, 9/30/16. S1CNO indicated that she had met with S6RN to discuss the incident involving Patient #1 and a decision was made to suspend S6RN for failing to comply with departmental and job expectations concerning documentation in the patient's medical record. S1CNO reported that usually all incidents involving EMTALA concerns resulted in a suspension if felt warranted by Administration. S1CNO further reported that she reviewed Patient #1's medical record again after surveyors left the hospital and was planning to terminate S6RN, but after meeting with the CEO it was decided not to terminate S6RN but to write an incident in her personnel file. S1CNO reported that she met with S6RN a second time on Friday, 10/7/16 and during this meeting S6RN decided to resign from the hospital.

When asked if she (S1CNO) had spoken with S6RN about details involving Patient #1's visit to the ED on 09/14/16, S1CNO indicated that she had. S1CNO indicated that S6RN reported the following in regards to Patient #1: S6RN reported Patient #1 was frequently in the ED for abdominal pain and problems and that he was there in the ED just a few days prior to 09/14/16. S6RN reported the ED was very busy that night and she (S6RN) just never looked at the ambulance face sheet or documentation to see Patient #1 had issues with psychiatric problems or suicidal ideations. S6RN reported Patient #1 was always in there with abdominal pain and he had told her that night he was having abdominal pain. S6RN reported being unaware of any psychiatric or suicidal issues with Patient #1. S6RN reported that after Patient #1 was triaged before he was seen by a mid-level practitioner or physician that he kept getting up off of the stretcher and going outside to smoke and going to the bathroom and would not stay in the room or on the stretcher to be seen. S6RN reported that when she asked Patient #1 to stay in his room he became increasingly verbally abusive to ED staff and told her he was refusing treatment and left the ED and went outside to smoke. S6RN reported it was then that she (S6RN) called for hospital security to accompany Patient #1 while he was outside. S6RN reported that Patient #1 did not want to stay and be seen in the ED. S6RN reported that she did not know why she had not charted more details other than she was just extremely busy that night. When asked if she (S1CNO) had spoken with the security officer involved. S1CNO indicated that she had. S1CNO reported that she had talked with S5Security but could not determine who actually said the patient could not come back in the ED and that security was just told by the nurse to stay with the patient until the police arrived.

In a phone interview on 10/13/16 at 6:40 p.m., S5Security reported that he remembers the incident on 09/14/16 involving Patient #1. S5Security reported Patient #1 comes to the ED frequently and always causes problems. S5Security further stated that he was not assigned to the ED that night but was assisting in training a new guy when he went to the ED and saw Patient #1. S5Security reported Patient #1 was always really loud and usually became verbally abusive to ED staff. S5Security reported that on this particular night Patient #1 was up walking around and the nurses were trying to keep him in his room on the stretcher. S5Security reported Patient #1 kept going outside and smoking and would not come back in when the nurse would try to get him to return to his room and that's when he started to become very loud and verbally abusive to the ED staff and would then go back outside. S5Security reported the charge nurse (S6RN) kept trying to get him to stay in the ED. S5Security reported Patient #1 eventually got his belongings and went outside of the ED by the ambulance entrance. S5Security reported S6RN told him Patient #1 had to leave because he would not stay in his room and that was why he (S5Security) was standing outside with Patient #1 when the police arrived. S5Security further stated that Patient #1 was sitting and stumbling around the ambulance entrance and would not leave the hospital grounds and that he (S5Security) stayed with the patient until the police arrived for the patient's safety. The surveyor asked who had made the decision to call the police and S5Security stated that another security guard had decided to call the police because he (S5Security) could not stay with the patient all night outside the ED to keep him from stumbling into the street into traffic and/or injuring himself. S5Security further stated that this was not the only time police had to come escort the patient from the hospital property because of his violent abusive behaviors. S5Security stated Patient #1 would not follow directions and leave the property so in the best safety of the patient the police were called. S5Security indicated the police arrived and the police officer talked with Patient #1 and then went into the ED to speak with the charge nurse while he (S5Security) remained outside with Patient #1. The police officer returned and then called an ambulance to pick up Patient #1.

Interview on 10/04/16 at 11:20 a.m. with S9LCPD/Captain revealed to surveyors that Patient #1 was well known to the Police Department and had a history of narcotics abuse and attempts of overdosing on pills. S9LCPD/Captain indicated that on 09/14/16 at approximately 6:52 p.m. was when the first contact was made with Patient #1. Patient #1 had a vehicle accident and drove a car into a utility pole and had fled the scene and was later apprehended by the police a few blocks away. During that encounter Patient #1 told the officers that he had taken a bunch of pills and wanted to harm himself that was how Patient #1 ended up at the ED at hospital (a). The officer on site had called for an ambulance to transport Patient #1 to the hospital and followed the patient to the ED. S9LCPD/Captain further stated that there are usually no written reports documented on these types of encounters, but after the LCPD was called back to the hospital (a) ED the second time he had made some unofficial documented notes of the evening's incident. He stated that S4Security had called for LCPD for the same person for behavior problems and S4Security had stated that Patient #1 could not re-enter the hospital. S9LCPD/Captain stated that there was A/V from the officers shoulder cam that the surveyors could view. Surveyor viewed A/V from 09/14/16 of the police officer arriving to hospital (a) where Patient #1 was sitting on a bench on hospital (a) grounds with a hospital (a) Security staff standing by the patient. Patient #1 stood and fell to the ground during verbal questioning by the police officer. S9LCPD/Captain stated that the police officer onsite called the ambulance to transport Patient #1 to hospital (b) ED.Review of the 2nd ambulance Prehospital Care Report Summary dated 09/14/16 revealed Patient #1 was picked up at hospital (a) at 9:42 p.m. and transported to hospital (b) at 10:02 p.m. The Chief complaint was listed as Suicidal Ideations, Behavioral Disorder, Psychiatric Emergency, and Overdose. Documentation revealed Patient #1's vital signs were as follows: B/P-136/95, P-128, R-16, pupils constricted. A narrative history documented by the ambulance paramedic revealed: "Upon arrival patient #1 was lying on the grass at the hospital parking lot with LCPD officer and unit 400 shift supervisor on scene. Per LCPD officer patient #1 was taken to the hospital ED for Suicidal Ideations and ingesting a hand full of Ambien. Per LCPD officer patient #1 was handcuffed by LCPD and transported by ambulance just prior to this incident. Per LCPD officer patient #1 was non-compliant with hospital ED staff, so they had security escort him out of the ED with his belongings and he was called. Therefore he (LCPD officer) called for an ambulance to have him taken to hospital (b) because the hospital ED said they did not want him back in the ED even though he was still on their property. Patient #1 was loaded and taken to hospital (b) ED for evaluation."

Review of the Emergency Provider Record dated 09/14/16 at hospital (b) revealed Patient #1 presented to the ED confused, lethargic, and unresponsive. Vital signs were documented as B/P-190/159, Pulse-122. Documentation revealed Patient #1 was intubated by the ED physician and placed on Mechanical Ventilation and admitted to the ICU unit.