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Based on a review of the ambulance trip report, medical record, complainant and staff interviews, policies and procedures, medical staff rules and regulations, it was determined that the facility failed to provide appropriate treatment within its capacity and capability for five (5) patients P (#1, 4, 6, 7,17) out of 20 sampled patients.

Findings were:

Cross refer to A-2406, as it relates to the facility's failure to provide five (5) patients P (#1, 4, 6, 7,17) out of 20 sampled patients with an appropriate Medical Screening Examination (MSE).

Based on a review of the ambulance trip report, medical record, complainant and staff interviews, policies and procedures, medical staff rules and regulations, the facility failed to provide five (5) patients P (#1, 4, 6, 7,17) out of 20 sampled patients with an appropriate Medical Screening Examination (MSE).

Findings were:

A review of the emergency medical services (EMS) report revealed that on 4/3/2022 at 1:17 am; the EMS crew responded emergent to the scene of an unconscious person; upon arrival, EMS observed a 23-year-old female patient (P) P#1 accompanied by a male. The male stated that P#1 had a lot to drink and experienced an unconscious episode. P#1 was alert and oriented upon EMS contact. P#1 was placed on the stretcher, vitals were taken, assessment was performed, and P#1 was transported to the facility.

A review of Patient (P) #1 medical record revealed that P#1 was presented to the facility's Emergency Department (ED) by EMS on 4/3/22 at 1:56 am. P#1 chief complaint was alcohol intoxication.

At 1:57 am. The registered nurse (RN) CC noted that P#1 presented to the ED via EMS for alcohol intoxication, P#1's fiancé called EMS because P#1 was not waking up. RN CC documented that P#1 was uncooperative with EMS and verbally aggressive at triage.

The emergency physician (EP) DD's first contact with P#1 was at 2:18 am. EP DD noted that P#1 fiancé called EMS due to P#1 falling into a bush and being disorientated. P#1 denied head trauma, seizure activity, or loss of consciousness. P#1 was uncooperative with EMS, and vitals were stable. Physical examination revealed that P#1 had slurred speech, elated mood, impulsive judgment, and cooperative behavior.

On 4/3/22 at 2:19 am, EP DD discharged P#1 as stable.

Further review of P#1's medical record failed to reveal ED orders, laboratory panel (labs), P#1's alcohol level, and comprehensive metabolic panel. P#1 was discharged a minute after first contact with EP DD. At 2:21 am, RN CC reviewed discharge instructions and follow-up care with P#1.

A telephone interview took place with the complainant on 6/14/22 at 1:12 pm. The complainant acknowledged the complaint and stated she had no additional information to add to the original complaint. The complainant stated she would rather not re-live everything again and explain her horrible situation at the facility for a second time. The complainant explained that she did not go to another hospital; after receiving no care at all at the facility, she went straight home.

An interview occurred with the emergency department director (ED) (BB) on 6/15/22 at 12:10 pm. ED BB explained the triage process by saying that when patients arrive at the facility, they are greeted by a registered nurse or paramedics who will ask the patient about their chief complaint and enter it into their medical record. The patient will then be transferred to the triage room for a focused assessment, and vital signs will be taken; the patient is then placed in a room for a provider to perform the medical screening exam, and in some cases, if the patient is stable, they may be sent to the waiting room to be called. ED BB said that once the provider assesses a patient and they decide to leave, it's considered leaving against medical advice (AMA). ED BB said they would attempt to get the patient to sign the AMA form. ED BB explained that most of the time, the staff are unaware of the patient leaving. However, if they know when the patient is leaving, they will encourage the patient to stay, and part of the process is for the provider to have a conversation with the patient letting the patient know the risk of leaving AMA. ED BB said if a patient leaves before being assessed by the provider, they are considered to have left without being seen. ED BB further explained that if staff observe the patient leaving, they should notify the provider that they witnessed the patient leaving. ED BB explained that the facility's nurses do not perform medical screening exams (MSE), and only providers have credentials to perform MSE. ED BB said all the facility staff is trained annually on EMTALA, which is part of the mandatory education.

An interview took place with the facility's emergency department chair (EDC) (AA) on 6/15/22 at 1:03 pm. EDC AA explained that, in general patients with altered mental status or intoxications, the provider would perform basic sets of laboratory tests. Depending on the patient's state and if the patient had a fall, the provider might order a computed tomography (CT) scan of the head. EDC AA said the provider might also screen for the blood alcohol level. EDC AA explained that for an agitated patient with a low alcohol level, Glasgow coma scale of 15, oriented times 4, and do not want to be seen, she would allow the patient to sign out as leaving against medical advice (AMA). EDC AA said that sedating a patient is on a case-by-case basis. EDC AA further explained that many patients are agitated and aggressive, and she would not want to sedate every patient. EDC AA explained that if a patient does not want her to touch them, it would be more appropriate to discuss the risk of leaving against medical advice and discharge the patient as AMA. EDC AA said she would not discharge such a patient as stable.

An interview with the registered nurse (RN) EE occurred on 6/15/22 at 1:19 pm. RN EE explained that he primarily works at the back in the emergency department and is not involved with patient triage. RN EE said patients are triaged and placed in a room or waiting area. RN EE further explained that two mid-level providers go around the lobby to start the process of a medical screening exam. RN EE said if such a patient leaves after seeing the provider, he would ask the front desk and attempt to look for the patient. RN EE said he would call the patient thrice, 15 minutes apart, before taking them off the board. RN EE further explained that, however, if he were aware of a patient saying they wanted to leave, he would encourage them to stay, and if they insisted on going, he would get them to sign the AMA form.

A telephone interview took place with the emergency physician (EP) DD on 6/16/22 at 9:50 am. EP DD explained that if a patient with alcohol intoxication presents to the ED, he would examine the patient's mental capacity. EP DD explained that if the patient had no capacity, he would conduct a full evaluation. EP DD said that if a patient had stable vital signs, no falls, and no complaints, there is a chance the patient could be discharged as stable. EP DD explained that if the patient with alcohol intoxication were belligerent and aggressive, the staff would try verbal de-escalation. EP DD explained that if the patient had stable transportation, was alert and oriented x4, and understood the risks of leaving without a full evaluation. He would discharge the patient as against medical advice (AMA).

P#4 arrived to the ED on 5/1/22 at 1:16 am as a result of a motor vehicle crash. An ED triage note dated 5/1/22 at 1:17 am revealed P#4's EMS reported P#4 was involved in a motor vehicle crash. An additional ED note on 5/1/22 at 3:00 am revealed P#4 was seen leaving the ED on the phone. P#4 expressed displeasure with the speed of service in the ED. P#4's ED disposition was left against medical advice .The facility failed to document an attempt to provide P#4 with a consultation to receive a MSE prior to leaving the facility or explain the risks of leaving prior to a MSE.

P#6 presented to the ED via ambulance on 3/26/22 at 4:47 am as a result of a motor vehicle accident. An ED triage note dated 3/26/22 at 4:59 am revealed EMS reported that P#6 was involved in a motor vehicle accident involving airbag deployment. P#6 complained of right shoulder and rib pain. An additional ED note entered on 3/26/22 at 6:13 am revealed P#6 walked out the front door and did not return. P#6's ED disposition was left without being seen before triage. The facility failed to ensure P#6 received consultation to receive a MSE prior to leaving the facility or explain the risks of leaving prior to a MSE.

P#7 arrived at the facility's ED on 1/25/22 at 8:38 pm. P #7's chief complaint was shaking. A review of the ED triage notes by RN II revealed that P#7's mother was checking P#7 in to be seen for shaking. Further review failed to reveal P#7's vital signs. At 11:10 pm, RN HH noted that P#7's grandmother took P#7 home. At 11:12 pm. The nurse practitioner (NP)(GG) documented P#7's discharge disposition as left against medical advice. Further review failed to reveal a signed AMA form or the risk of leaving AMA being discussed with P#7's family.

P#17 presented to the facility's ED on 6/1/22 at 4:13 am complaining of ovarian pain and a history of ovarian cysts. Further review of P#17's medical record failed to reveal a signed AMA form or a discussion between the provider and P#17 regarding the risk of the decision to leave against medical advice. P#17 ED disposition was set as left against medical advice on 6/1/22 at 5:21 am.

A review of the facility's policy titled "Left without being seen", policy number ES-05, last reviewed 11/2/2020, revealed that the purpose of the policy is to define a process for handling adult patients with decisional capacity who leave after requesting treatment but before being seen by a provider while respecting the patient's right to refuse any medical treatment. Further review of the policy revealed that an adult with decisional capacity has the right to refuse any medical treatment. The provider, registered nurse, paramedic, ED technician, or patient assess services would document the patient's name, date, time, and why the patient left (if known). When a team member is aware that the patient wishes to leave, a medical screening exam (MSE) is offered to the patient prior to the patient leaving. The offer and patient's response to the MSE is documented in the medical record.

A review of the facility's policy titled "Leaving Against Medical Advice (AMA)", policy number PE-14-01, last reviewed 11/2/2020, revealed that the purpose of the policy is to define a process for working with adult patients with decision-making capacity who wish to leave against the medical advice of a provider while respecting the patient's right to refuse any medical treatment. The attending provider, registered nurse, and paramedic will advise the patient of the risks involved in discontinuing treatment or leaving before being discharged. The staff will encourage the patient to continue in their prescribed course of medical treatment if a patient leaves before being advised on the risks involved with discontinuing treatment or being discharged. The facility staff will attempt to locate the patient; attempts made to locate the patient are documented in the medical record. When patients choose to leave the hospital against medical advice, healthcare providers are not prevented from providing the patient with various medical help to optimize their health to the extent possible in the situation. It is important that patients do not feel abandoned because of their choice to leave the hospital and that they feel safe to return to the hospital if needed. The facility staff should document the patient who insists on leaving against medical advice in the medical record and attempt to obtain the patient's signature on the AMA acknowledgment form. Signatures act as patients' acknowledgment of patient awareness of the risks of leaving AMA. Patient refusal to sign an AMA form does not relieve the provider of the responsibility for the explanation of documentation of risks. Documentation includes that the patient refused to sign the AMA form.

A review of the facility's policy titled "Emergency Medical Treatment And Labor Act -EMTALA," policy number LD-108, last reviewed 12/18/21, revealed that the hospital will provide an appropriate medical screening examination within the capacity of the hospital's Dedicated Emergency Department, including ancillary services routinely available to determine if an emergency medical condition(EMC) exist; and the hospital will : (a) provide to an individual who is determined to have an EMC such further medical examination and treatment as is required to stabilize the emergency medical condition, or (b) arrange for transfer of the individual to another medical facility in accordance with the procedures set forth by the hospital.

A review of the facility's medical staff rules and regulations revealed that patients presenting for emergency care at a hospital with an emergency department should have a medical screening examination (MSE) to determine, with reasonable clinical confidence, whether an emergency medical condition exists.