HospitalInspections.org

Based on interviews, review of EMS (Emergency Medical Services) reports and EMTALA (Emergency Medical Treatment and Labor Act) Policies and Procedures, Hospital 2 failed to:

1. Provide a Medical Screening Examination (MSE) for two of 29 sampled patients: Patient Identifier # 1, a patient who returned to the ED on 5/27/13, minutes after leaving Against Medical Advise (AMA) and PI # 2, a patient who presented to the Emergency Department (ED) via ambulance on 3/5/13 with a chief complaint of weakness. Refer to findings at tag A2406.


2. Provide Stabilizing Treatment for PI #1 and PI # 2, two of 29 sampled patients. Refer to findings at tag A2407.


3. Arrange, implement and document an appropriate transfer for PI # 1 and PI # 2. Refer to findings at tag A2409.


Hospital 2's deficient practice effected PI # 1 and PI # 2, two of 29 sampled patients who presented to Hospital 2's Emergency Department and has the potential to negatively effect all patients who present to Hospital 2's ED for a Medical Screening Examination to determine if an Emergency Medical Condition exists, require stabilizing treatment, and / or require or request transfer from Hospital 2 to another hospital.



These citations were written as a result of the investigation of Complaint Number AL00029174.

Please refer to findings at:

A- 2405 / 489.20 (r)(3) - Emergency Room Log
A - 2406 / 489.24(r) and 489.24(c) - Medical Screening Examination;
A - 2407 / 489.24(d)(1-3) - Stabilizing Treatment and
A - 2409 / 489.24(e)(1-2) - Appropriate Transfer.

.0Based on interviews and review of EMTALA policies and procedures, Hospital 2 failed to document any information in the Emergency Department (ED) Central Log concerning Patient Identifier (PI) # 1's return to the ED on 5/27/13 when PI # 1's representative returned to the ED and notified staff that something was wrong with PI # 1. This deficient practice effected 1 of 29 sampled patients presenting to Hospital 2's ED and had the potential to negatively effect all patients who present to Hospital # 2's ED.

Findings Include:

Review of PI # 1's medical record from Hospital 2 revealed the following:

Patient arrived in ED at 04:20 AM.

Triage began at 04:30 AM and includes the following documentation:

04:34:12 - Pt c/o (complained of) SOB (shortness of breath) with occas. (occasional) CP (Chest pain) on & off for the last month. Worse tonight, " I feel like I can' t catch my breath." Some n/v (nausea/vomiting) when pain is worst.

0435: Temp: 96.9, Pulse 84, Blood Pressure: 135/89, Blood Glucose 256.

4:38:33: Patient was taken to ED room 24.

04:54:24: "Awaiting MD (Medical Doctor) eval (evaluation)."

06:34 AM - The ED Physician (EI # 5) documented, "This case is a certified medical emergency..."

06:46:22 - EI # 8 documented, "... RN (Registered Nurse) went to pts (patient's) room. Pt asked to see (doctor) - RN asked what this was concerning and pt became belligerent. Pt was not in stretcher, did not have O2 on, and began cursing @ RN. RN explained to pt that need to be in bed with O2 on. Security called. Pt wants to leave ama (against medical advice). MD (Medical Doctor) (EI # 5) informed. Pt informed of risks of leaving ama. Pt refused to sign AMA form. Pt removed own IV would not allow (nurse) to apply gauze. Pt states, "You can't keep me here, I am not under arrest." Pt walked to truck by own power with security. Threatening security along the way..."

06:48:58 - ED disposition set to eloped per ED Physician (EI #5).

06:49 - ED Physician (EI # 5) documented, ED Course/Plan, "... Chest pain: SOB (Shortness of breath) Diagnosis management comments: The patient became hostile and belligerent and had to be removed from the emergency department prior to my evaluation. I did not lay eyes on this patient ... Patient Progress: stable..."

Interview with Employee Identifier (EI) # 8, Staff RN ED at Hospital 2, 0630 - 1830 shift, on 6/26/13 at 10:50 AM:

EI # 8 verified he was the RN assigned to PI # 1 when the patient left the ED Against Medical Advice (AMA) on 5/27/13 and returned several minutes later.

Sometime around 0630 on 5/27/2013, EI # 8 reported PI # 1 said he was leaving and PI # 1 abruptly left the ED AMA before he was seen by a physician.

Minutes later, the ED Liaison (EI # 9) informed the charge nurse that a female representative for PI # 1 entered the ED waiting area and reported something was wrong with PI # 1. The representative said PI # 1 was in the truck parked in the ambulance bay and was possibly having a seizure. . According to the EI # 8, as he and the ED Charge Nurse (EI # 4) arrived at the ambulance bay doors, a truck allegedly containing PI # 1, was driving off.


Interview with EI # 9, ED Liaison / Hospital 2, on 6/26/2013 at 3:30 PM:

EI # 9 stated the first time PI # 1 left the ED on 5/27/13 she observed PI # 1 and staff walking outside in the ambulance bay. PI # 1 got in a truck and left the ED.

A few minutes later a female driving a truck pulled into the ambulance bay, got out of the truck and walked into the ED waiting area. The female reported (PI # 1), who is reportedly in the truck, was having a seizure or "something." "They (Hospital 2 staff ) just made us leave." EI # 9 said she initially advised a staff RN about the complaint. EI # 9 said she then saw the ED Charge Nurse (EI # 4) and advised her of the situation. According to EI # 9, the Charge Nurse (EI # 4) told the staff RN (EI # 8) to accompany her to the ambulance bay to check on the patient (PI # 1).


EI # 9 stated she saw a security officer standing by the truck in the ambulance bay talking with the female who reported the concern about
PI # 1. Reportedly the officer told the female the police are called when a person who has been asked to leave the hospital does not leave. Allegedly the female said, "Well I'm not going to jail on Memorial Day." She got into the truck and drove away. EI # 9 stated she saw the Charge Nurse (EI # 4) and another staff member (unsure of identity) in the ambulance bay as the truck drove away.


Interview with EI # 4, RN, Day shift ED Charge Nurse at Hospital 2, on 6/25/13 at 4:57 PM:

Shortly after PI # 1 left the ED, the ED Liaison (EI # 9) came to me and said PI # 1 is back. According to EI # 4, she and a staff RN (EI # 8) went to the ambulance bay just as the female was driving the truck away from the bay area. "I never saw the patient (PI #1) after he walked out with the security guard."


Interview with EI # 6, Protective Services Officer at Hospital 2, 0630 to 1830 Shift, on 6/26/13 at 1:08 PM:

Relationship to PI # 1: Conversation with female (driver) who accompanied PI # 1 to Hospital 2's ED on 5/27/13.

EI # 6 said at the beginning of the day shift, he was informed by the Protective Services night shift Team Leader that PI # 1 had been removed from the ED due to aggressive behavior and cursing staff. He reported he was advised PI # 1 and the person accompanying PI # 1 had been asked to leave the hospital.


The Team Leader pointed to a truck parked in a space near Circle One (Hospital 2 Property) and said, "That's the truck." EI # 6 said the truck pulled away as he walked toward the vehicle. According to EI # 6, before he could walk back to the ambulance bay at the ED, the truck pulled in and parked in the bay. A female was standing outside of the truck when EI # 6 arrived. EI # 6 said he asked the female if the truck was her vehicle and she said yes. The officer said to the female, "Ya'll have been asked to leave the property." The female reportedly said, "I don't know what to do." According to EI # 6, the female did not say anything about PI # 1. The officer stated he said, "I don't know, but you were asked to leave here." The female returned to the truck and pulled away. EI # 6 was asked if he/she saw Patient #1. EI # 6 said no. All he/she could see was a leg.

A review of Hospital 2's ED Log on 6/24/13 revealed there was no documentation in the log regarding PI #1's return to the ED on 5/27/13. .

Hospital # 2's Policy & Procedure review revealed the following:

Policy Title: Medical Screening Examination Policy revealed in part, ..."Additionally, an ambulance or private vehicle transporting a patient to the hospital which arrives anywhere on hospital property is considered having come to the hospital and the patient must be offered a medical screening exam... 3) In the event the patient has not been registered, document the patient's visit and disposition on the centralized log in the emergency department..."
The hospital failed to ensure their policy was followed as evidenced by PI # 1's return visit to Hospital 2's ED was not documented in the ED Log. Additionally, the policy was not followed as evidenced by the ED staff failing to consider that on 5/27/2013 when Patient # 1 arrived on hospital property (ambulance bay area) for the second visit, as stated in the hospital's policy was "considered having come to the hospital."

Based on medical record reviews, review of Emergency Medical Services (EMS) reports, Hospital EMTALA (Emergency Medical Treatment and Labor Act) Policies and Procedures (P & P), Hospital 2's Action Plan and Medical Staff Rules and Regulations, Hospital 2 failed to provide a medical screening examination for two of 29 sampled patients presenting to Hospital 2's Emergency Department (ED) to determine whether or not an emergency medical condition existed. This deficient practice effected Patient Identifier (PI) # 1, a patient who returned to the Emergency Department after leaving Against Medical Advice on 5/27/13, and PI # 2, a patient who presented to the ED on 3/5/13 via ambulance with an arrival complaint of weakness and nausea. This deficient practice has the potential to negatively affect all patients who present to Hospital 2's Emergency Department (ED).

Findings Include:

1. Review of PI # 1's medical record dated 5/27/2013 from Hospital 2 revealed the following:

Patient arrived in ED at 04:20 AM.

Triage began at 04:30 AM. The following documentation was included in the Triage notes:

04:34:12 - Pt. c/o (complained of) SOB (shortness of breath) with occas. (occasional) CP (Chest pain) on & off for the last month. Worse tonight, "I feel like I can't catch my breath." Some n/v (nausea/vomiting) when pain is worst.

04:35 - Vital signs - Temperature 96.9 orally, Pulse 84, Blood pressure 135/89 sitting, Oxygen Saturation 100% on room air, Blood Glucose 256 (normal range 70 -99), Pain 9 (0-10 scale with 0 being no pain and 10 being worst pain), location chest.

04:38:33 Patient was taken to ED room 24.

04:39:21 Orders for Cardiac monitoring, Oxygen set-up, Pulse ox (Oxygen monitoring) CBC (Complete blood count) with differential, Comprehensive metabolic panel, PTT (Partial Thromboplastin Time), INR (International normalized ratio), Cardiac enzymes, BNP (Brain Natriuretic Peptide), Urinalysis w/o (without) microscopic, ECG (Electrocardiogram), Chest x-ray.

04:53: The RN documented the placement of an 18 G (gauge) peripheral IV (intravenous) to the left antecubital area.

04:54: The RN documented, "Awaiting MD (Medical Doctor) eval (evaluation)."

Lab results were documented as follows:
05:09 - CBC (complete blood count) with differential with abnormal results included the following:
WBC (White blood count) = 17.7 (normal range 5.0 - 10.0)
RBC (Red blood count) = 5.43 (normal range 4.20 - 5.40)
Hematocrit = 49 (normal range 36 - 48 % - proportion of total blood volume that is composed of red blood cells)

MCH (Mean corpuscular hemoglobin) = 32 (normal range 26 - 31)

05:28 - BNP = 51.87 (normal range <50 years old 450 pg/mil - picograms/milli-liter)

05:30 - Comprehensive metabolic panel - Glucose = 287 (normal range 70 - 99)

06:18 - Employee Identifier (EI # 8), Registered Nurse (RN) was assigned to the patient. EI # 8 documented the patient's assessment as follows: Neurological - within defined limits, pulmonary assessment: dry cough, skin assessment: within defined limits, cardiac assessment: within defined limits, normal sinus rhythm

06:19 - Pulse 87, Blood pressure 139/92, respirations 20, O2 (Oxygen) saturation 97%.

06:28: 12 Lead EKG (electrocardiogram) interpretation by ED Physician: Sinus Rhythm, rate 70, normal PR interval, normal ST segment...

06:34 AM - EI # 5, Emergency Department (ED) physician, documented, "This case is a certified medical emergency ..."

06:46: EI # 8 documented, "... RN went to pts (patient's) room. Pt asked to see (doctor) - RN asked what this was concerning and pt became belligerent. Pt was not in stretcher, did not have O2 on, and began cursing @ RN. RN explained to pt that need to be in bed with O2 on. Security called. Pt wants to leave ama (against medical advice). Name of ED Physician (EI # 4) informed. Pt informed of risks of leaving ama. Pt refused to sign AMA form. Pt removed own IV would not allow (nurse) to apply gauze. Pt states, "You can't keep me here, I am not under arrest". Pt walked to truck by own power with security. Threatening security along the way ..."

06:48: ED disposition set to eloped as documented by EI # 5.

06:49 - EI # 5 (ED Physician) documented, ED Course/Plan, "... Chest pain: SOB (Shortness of breath) Diagnosis management comments: The patient became hostile and belligerent and had to be removed from the emergency department prior to my evaluation. I did not lay eyes on this patient...Patient Progress: stable..."


Review of Patient Identifier (PI) # 1's medical records from Hospital # 1(Hospital where Patient # 1 was taken by his/her representative after leaving Mobile Infirmary) revealed PI # 1 returned to Hospital # 1's ED at 07:03 AM on 5/27/2013 by private vehicle.

Review of the Medical Screening/Nursing Assessment revealed the patient's chief complaint was Cardiac Arrest ... possible seizure (sudden disruption of the brain's normal electrical activity as evidenced by altered consciousness and/or other neurological manifestations), CPR (cardiopulmonary resuscitation). PI# 1's primary assessment revealed the patient was unresponsive... skin was warm and dry with no movement.

Further documentation revealed, "... 35 yom (year old male) presents to ED, POV (privately owned vehicle) for possible seizure ... pt was found to be pulseless (having no pulse, lifeless) and apneic (temporary absence or cessation of breathing). CPR initiated. Pt taken to TR (Trauma Room) with CPR cont. (continued) 7.0 ETT (endotracheal tube) placed & confirmed with ... BBS (bilateral breath sounds) (no) epigastric gurgling ... ACLS (Advanced Cardiac Life Support) ... Pt defibrillated ... firing for VF (ventricular fibrillation: rapid erratic heartbeat - medical emergency) with no response except asystole (absence of a heartbeat). Heroic measures performed. CPR and defib ... No signs of life... Asystole... pt had been at (Hospital # 2) PTA (prior to arrival) ..." PI # 1's time of death was documented as 07:22 AM.


Interview with Employee Identifier (EI) # 8, Staff RN - ED at Hospital 2, 0630 - 1830 shift, on 6/26/13 at 10:50 AM. Relationship to PI #1: RN assigned to PI # 1 when the patient left Against Medical Advice.

Sometime around 0630 on 5/27/2013, EI # 8 said he was notified that PI # 1 wanted to see the doctor. EI # 8 went into PI # 1's room. According to EI # 8, PI # 1 was cursing, yelling and hostile. PI # 1 stated he was hurting, had completed multiple tests and wanted to leave. The RN (EI # 8) said he explained to PI #1, the "MD (Medical Doctor) has to see you." Security was called. PI # 1 said, "You can't keep me here." The RN said he reviewed the AMA form with PI #1, but the patient refused to sign the form. PI # 1 pulled out his IV and was bleeding on the floor. As PI # 1 was leaving the ED, the RN said he was advising the patient of the risks of leaving without being seen by a physician including endangerment of his life.


According to EI # 8, the physician was notified, "As a courtesy that PI # 1 wanted to leave AMA." EI # 8 indicated there was not enough time for the physician to see PI #1, once PI # 1 decided to leave AMA. EI # 8 said PI # 1's departure was, "Not really an AMA," but staff still attempts to get the AMA form signed by the patient. According to EI # 8, Hospital 2 does not have an elopement form. The ED Physician reportedly said, "O.K. I haven't even seen him." According to EI # 8, PI # 1's request to leave was abrupt. While walking to his truck, PI # 1 was "loud and belligerent." PI # 1 said, "You can't keep me here."


The RN (EI # 8) said PI # 1 was not short of breath and was able to yell without difficulty. EI # 8 described PI # 1 as "verbally combative." EI # 8 denied that PI #1 threatened him. According to EI # 8, he reviewed PI # 1's vital signs and lab results with the ED Physician.

Minutes later, the ED Liaison (admitting clerk), informed the charge nurse that PI # 1 was reportedly seizing in the ambulance bay. According to EI # 8 (Staff RN), as he and the ED Charge Nurse arrived at the ambulance bay doors, a truck allegedly containing PI # 1, was driving off. The RN could not see the driver or the patient. Later, (time unknown) Hospital 2's ED received a call from Hospital 1's ED asking for PI # 1's history. Hospital 1 reported staff had, "Just pulled PI # 1 out of the truck." The RN said he was informed that PI # 1 died. EI # 8 said he and the ED Physician discussed the case to determine if anything was missed during PI # 1's visit. We determined we did not miss anything.


Interview with EI # 5, MD, ED Physician at Hospital 2, 0600 - 1830 Shift, on 6/25/13 at 8:14 PM:

Relationship to PI # 1: ER Physician on 5/27/13 when PI # 1 left AMA.

EI # 5 was asked if he recalled PI # 1 and he responded, "No, I never laid eyes on him... the shift changes at 0600. I picked up 3 to four charts and clicked on. I was just starting my day. The patient (PI # 1) had already gone when I got ready to see him." When asked if anyone told him about PI # 1, EI # 5 said, "They told me generically that the patient (PI #1) was in the room. I said...I'll get around to him."


EI # 5 verified he documented PI # 1's visit on 5/27/2013 was a certified medical emergency in PI # 1's medical record. According to EI # 5, he based this decision on a lay person's definition of an emergency. "If a patient shows up. A lay person would consider the patient's presentation to the Emergency Room an emergency." EI # 5 said he documents every patient who presents to the ED is a certified medical emergency. EI # 5 was advised his documentation in the medical record revealed PI # 1 was stable at discharge. The physician was asked to explain how he determined the patient was stable, if he did not assess PI # 1. EI # 5 said, "I assume if the patient (PI # 1) left on his own power the patient was stable."


Interview with EI # 6, Protective Services Officer at Hospital 2, 0630 to 1830 Shift, on 6/26/13 at 1:08 PM:

Relationship to PI # 1: Conversation with PI # 1's representative (driver) who accompanied PI # 1 to Hospital 2's ED on 5/27/13.

EI # 6 said when he began the day shift, he was informed by the Protective Services night shift Team Leader that PI # 1 had been removed from the ED due to aggressive behavior and cursing staff. PI # 6 said he was advised PI # 1 and the person accompanying PI # 1, had been asked to leave the hospital.


The Team Leader pointed to a truck parked in a space near Circle One (Hospital 2 Property) and said, "That's the truck." EI # 6 said the truck pulled away as he walked toward the vehicle. According to EI # 6, before he could walk back to the ambulance bay, the truck pulled in and parked in the bay. A female was standing outside of the truck when EI # 6 arrived. EI # 6 said he asked the female if the truck was her vehicle and she said yes. The officer said to the female, "Ya'll have been asked to leave the property." The female reportedly said, "I don't know what to do." EI # 6 reported the female did not say anything about PI # 1. According to EI # 6 (security officer) he said, " I don't know, but you were asked to leave here." The female returned to the truck and pulled away. EI # 6 was asked if he saw PI #1 and he said no. EI # 6 said he could only see a leg. EI # 6 was asked if ED staff were present in the ambulance bay. EI # 6 said, "No. They (staff) came out as the truck was pulling away." EI # 6 was asked if the hospital has a policy and procedure regarding management of aggressive behavior and he said no. "We've been taught it's hands off."


Interview with EI # 4, RN, Day shift ED Charge Nurse at Hospital 2, on 6/25/13 at 4:57 PM:

Relationship to PI # 1: Charge Nurse when PI # 1 arrived at Hospital 2's ED on on 5/27/13:

According to EI # 4, she went to Room 24/25 (room assigned to PI # 1) to check the emergency cart and saw a male sitting in a chair. EI # 4 said she noted a female lying in the bed. EI # 4 stated she left the room never realizing (at the time) the female was not the patient. "Twenty minutes later, the RN assigned to PI #1 came out of the room (room 24/25) and asked me to get security. The patient (PI # 1) is irate, belligerent and wants to leave."


EI # 4 (Charge Nurse) reports she told the RN assigned to PI # 1 to talk with the ED Physician about PI #1. EI # 4 said when a patient wants to leave we get the MD involved - make MD aware. The Charge Nurse reported she went to notify security and saw security walk in PI # 1's room. Several minutes later, EI # 4 said she saw a security guard and PI # 1 walking out of the ED. PI # 1 was not wearing a shirt.

Shortly after PI # 1 left the ED, the ED Liaison came to the treatment area and said PI # 1 is back. EI # 4 said she and a staff RN went to the ambulance bay just as the female was driving the truck away from the bay area. "I never saw the patient (PI #1) after he walked out with the security guard." ED staff from Hospital 1 called to,"Let us know the patient (PI # 1) was there." EI # 4 was asked if PI # 1 was seen/evaluated by the ED physician at Hospital 2 and she said, No." According to EI # 4, she informed the ED Physician that a female returned to the ED and reported PI # 1 was having seizures. ED staff went to the ambulance bay to check PI #1, but the female drove away before staff reached the vehicle. EI # 4 said she was asked by the physician to find out what happened to PI # 1. EI # 4 said she contacted ED staff at Hospital 1 and was advised PI # 1 coded and expired. EI # 4 was asked to describe the ED Physician's response and she stated the physician advised her to inform the House Supervisor at Hospital 2 about the incident. The ED Director and the ED Manager were in the ED and they were advised about the incident.


Interview with EI # 7, ED RN at Hospital 2, 1830 - 0630 shift, on 6/26/13 at 8:49 AM:

Relationship to PI # 1: Triage of PI # 1 on 5/27/13.

EI # 7 was asked if she remembered PI # 1 and she said yes. "He (PI # 1) cursed us out the entire time he was in triage." EI # 7 accompanied PI # 1 to room 24 and reports she never saw PI # 1 after this encounter.


Interview with EI # 1, ED RN at Hospital 2, 1830 -0600 Shift on 6/25/13 at 4:07 PM:

Relationship to PI # 1: RN assigned to PI # 1 at 0452 on 5/27/13:

EI #1 described PI # 1 as "abrasive and very demanding." PI # 1 wanted his girlfriend in the room (Room 24) with him and became very angry when EI #1 was unable to find her.


Interview with EI # 2, RN/Day Shift House Supervisor at Hospital 2, on 6/25/13 at 4:40 PM:

EI # 2 stated he was informed by an ED staff RN that PI # 1 left AMA (Against Medical Advice) on 5/27/2013. Per the RN's report, the patient was not in the ED bed, but had been sitting in a chair and refused oxygen. PI # 1's female friend had been laying in PI # 1's bed.


Interview with EI # 9, ED Liaison Hospital 2, on 6/26/2013 at 3:30 PM:

EI # 9 stated the ED Charge Nurse came to the waiting area on 5/27/13 to obtain assistance from the security officer to, "Make this patient (PI # 1) leave because he was cursing all of the nurses." From a monitor at the registration desk in the waiting area, EI # 9 said she could see
PI # 1 and staff walking outside in the ambulance bay. Although there is no audio monitoring, EI # 9 said she could hear PI # 1 and staff when they were in the ambulance bay when the automatic doors opened (doors in close proximity to EI # 9's desk). According to EI # 9, she heard PI # 1 say, "This is not right. Why are ya'll making me leave. I'm sick." PI # 1 got in a truck and left the ED.


"A few minutes later a female driver pulls into the ambulance bay, walks into Hospital 2's ED waiting area and says her boyfriend (PI # 1) is having a seizure or something. They (staff) just made us leave." EI # 9 said she went to the ED (patient area) and advised a staff RN about the female's complaint. EI #9 alleged the staff RN said, "We're not going to get him (PI # 1) out of the truck. We don't do that." EI # 9 said she then advised the ED Charge Nurse of the situation. According to EI # 9, the Charge Nurse told the staff RN to accompany her to the ambulance bay to check on the patient (PI # 1).


EI # 9, ED Liaison, stated she continued to watch the video camera and saw a security officer standing by the truck in the ambulance bay talking with the female who reported the concern about PI # 1. Reportedly the officer told the female the police are called when a person has been asked to leave and does not leave. The female said, "Well I'm not going to jail on Memorial Day." She got into the truck and drove away. EI # 9 stated she saw the Charge Nurse and another staff member (unsure of identity) in the ambulance bay. EI # 9 said the female, "Did not seem terrified, she was not crying and did not seem to be in a panic."

The hospital failed to ensure their policies were followed as evidenced by failing to ensure that on 5/27/2013 when Patient # 1 was transported to the hospital via private vehicle and arrived at the at the hospital's ambulance bay, "the patient must be offered a medical screening examination." On 5/27/2013 after a request was made by the representative on Patient # 1's behalf for medical assistance, the hospital failed to provide a medical screening examination to determine whether or not an emergency medical condition existed.


2. PI # 2: Review of the EMS Patient Care report dated 3/5/13 revealed PI # 2 was transported from a residence to Hospital 2:


Review of the EMS Patient Care report dated 3/5/13 revealed PI # 2's chief complaint was weakness and AMS (altered mental status). Pt's friend called 911 today at 1930 due to the patient presenting with weakness unknown onset. (Patient) is responsive to verbal stimuli, not alert and O (oriented) times 2 only. Pt has not been seen "for a few days" and pt's friend reports pt has not been compliant in taking retroviral (for HIV) (Human Immunodeficiency virus) meds as directed. (A) (Assessment) Pt responsive to verbal stimuli, lethargic, O x 2 (oriented times 2) ... speech (?) Pt denies HA (headache), No trauma, PERRL (pupils equal, round reactive to light). BBS ... without SOB (shortness of breath), no CP (chest pain) (pt denies pain anywhere except LLQ (left lower quadrant) on palp. (palpation) ... skin dry, warm (normal) color but a few lesions (closed) are noted (2 on abd (abdomen) a few on arms..." Arrived at destination (Hospital 2) at 20:45.

Review of the electronic copy of the EMS (Emergency Medical Services) report revealed the patient was conscious, but not alert. Responded to verbal stimuli only and responded to most questions only after question is asked multiple times; does not answer all questions. PI # 2 had a blunted affect, exhibited some lethargy in route and upon arrival at Hospital 2's ED. ECG (Electrocardiogram) showed sinus tachycardia at 128 -140 BPM (beats per minute). PI # 2's blood pressure was 155/108. PI # 2 confirmed nausea but, no vomiting. PI # 2's temperature was 98.5. PI # 2's abdomen was soft with tenderness to palpation of LLQ (left lower quadrant).

PI # 2 was transported to (Hospital 2) to the (ED) waiting room with the following incident: "... After obtaining wheelchair and attempting to assist pt from stretcher to the wheelchair (via stand & pivot) Pt repeatedly refused attempts to get off of the stretcher. Pt pushed attendant 1 away twice, and the second time, Pt picked his legs back up on the stretcher, curling his legs up, lying back and appearing to take a nap. At this point, ER (Emergency Room) Charge RN (Registered Nurse) attempted to verbally motivate pt to get off the stretcher without success. Ultimately, (Hospital # 2) ... Security Officer (an off duty Police Officer) had to physically remove pt from the stretcher, Though pt did not suffer any apparent injuries in this process. Pt was wheeled to waiting rm and checked in (with admissions) with transfer of care, written & verbal report to ER triage RN. Treatment, transport & transfer of care without additional incident except as noted in this section..."

Review of Patient Identifier (PI) # 2's medical record from Hospital 2 revealed the patient presented to Hospital 2's ED on 3/5/13 at 9:00 PM by ambulance with weakness and nausea. EI # 15, Registered Nurse (RN) Triage Nurse, documented PI # 2's disposition at 22:12 was AMA/LWBS (Against medical advice/Left without being seen) before triage. There was no other documentation in PI # 2's medical record to indicate that a medical screening examination was completed to determine whether or not an emergency medical condition existed.

During a review of the hospital's security tape, (dated 3/15/2013), the patient was seen lying on the floor between the ED and the ambulance bay. A security officer picked up the patient and placed him in a wheelchair. Next, the officer was seen pushing the wheelchair in the driveway of the ambulance bay away from the Emergency Department. During an interview with EI # 4 on 6/25/13 at 2:36 PM, the Director Protective Services, said the officer transported the patient (PI # 2) off hospital property.

Review of the Fire-Rescue Field Triage Sheet dated 3/6/13 (time not documented) revealed the incident location was "Dead end Center St at (Hospital # 2) ..." The Fire-Rescue staff member documented, "... Pt was kicked out of (Hospital 2) at 2200 per (Hospital 2) staff. Vitals taken ... (Ambulance company name) ..." (See EMS Report # 2 below)

Review of EMS Report # 2 revealed a call was received at 02:07 AM on 3/6/13 for "One Down" (person down on the ground). EMS arrived at the location and found PI # 2 on the ground for "4 hours" after security told to leave (Hospital 2) ... Pt has weakness and AMS (altered mental status). Pt would not speak. Pt skin very cold...given supportive care ...moved to stretcher...transported to (Hospital 3- another acute care hospital)."

Interview with EI # 11, RN ED Charge Nurse at Hospital 2, on 6/26/13 at 10:00 AM.


EI # 11 stated PI # 2 arrived via EMS at Hospital 2 on 3/5/13. EI # 11 directed EMS staff to take PI # to triage to be signed in as a "regular patient." EI # 11 was asked to identify the criteria used to determine
PI #2's appropriateness for triage versus direct placement in an ED bed. EI # 11 verified the criteria as PI # 2's complaint of weakness, noncompliance with medications per EMS staff, PI # 2's age and vital signs. EI # 11 said PI # 2 did not want to get off of the stretcher and into a wheelchair, but was eventually compliant without assistance. EI # 11 said she was advised PI #2 did not want to be treated and "walked off." EI # 11 stated she was informed PI # 2 told the triage nurse, "Get your "f....g hands off me."

The only information documented in PI # 2's medical record on 3/5/13 includes, "2100: Arrived ED. 22:12: AMA/LWBS - LWBS (Left Without Being Seen) before triage. 22:13: Pt. (patient) dismissed."


Interview with EI # 12, ED Staff RN Hospital 2, on 6/26/13 at 9:25 AM:

According to EI # 12, the Charge Nurse directed PI # 2 to triage after PI # 2 arrived in the ED via ambulance. EI #12 reported seeing EMS staff and hospital security attempting to move PI # 2 from a stretcher to a wheelchair. EI # 12 described the patient as "kind of combative." "He (PI # 2) was sitting up and all of a sudden refused to do anything." According to EI # 12, the ED was very busy and she took report from EMS staff for the triage nurse. After giving report to the triage nurse, EI # 12 said she had no further contact with PI # 2.



Interview with ED Admission Assistant at Hospital 2, EI # 13, on 6/26/13 at 2:20 PM:


EI # 13 stated she was asked by a paramedic on 3/5/13 to notify security assistance was needed because PI # 2 was refusing to get off a stretcher and into a wheelchair. EI # 13 said she notified the officer, identified as an off duty policeman, as requested. PI # 2 was assisted to a wheelchair and brought to the ED waiting area. EI # 13 did not interact with PI # 2, but registered PI # 2 via computer with information provided by the paramedic. After PI # 2 was in the triage room, EI # 13 reports she heard screaming. PI # 2 was out of the wheelchair and saying he did not want to be seen. EI # 13 reports security escorted PI # 2 out of the triage room.



Interview on 6/25/13 at 2:36 PM with EI # 14, Director Protective Services at Hospital 2:

According to EI # 14, PI # 2 had been disruptive and non-compliant in the triage area. PI # 2, "Went to the ground" at the ambulance bay doors when exiting the ED on 3/5/13. PI # 2 was put in a wheelchair and escorted off hospital property by a security officer who is no longer employed by Hospital 2.


The triage nurse (EI # 15) and security officer (EI # 16) associated with PI # 2's visit to the ED at Hospital 2 on 3/5/13 are no longer employed by the hospital.



Hospital # 2's Policies & Procedures reviews revealed the following:

1. Medical Screening Examination Policy
For individuals seeking treatment on hospital property, the facility will provide a medical screening examination conducted by a qualified medical person to determine if an emergency medical condition exists. Additionally, an ambulance or private vehicle transporting a patient to the hospital which arrives anywhere on hospital property is considered having come to the hospital and the patient must be offered a medical screening exam ...

A registered nurse may perform the medical screening examinations to ascertain emergency medical conditions. Questionable determinations if an emergency medical condition shall require a focused physical exam and physician review.

If an emergency medical condition exists, a chart documenting findings shall be initiated. Anyone presenting for examination will be recorded on a centralized log. Patient priorities shall be established according to triage guidelines with the most critically ill patients being given first priority.

Medical Screening Examination Procedure
A. A qualified medical person, either a registered nurse or physician shall:

1) Conduct medical screening examination upon arrival.

2) Screen as follows:
a. Assessment of chief complaint;
b. Assessment of general appearance;
c. Attainment of vital signs;
d. Evaluation of mental status;
e. Performance of an applicable Focused Physical Exam as indicated by clinical finding during Medical Screening Examination.

3) Document assessment of clinical findings from the medical screening exam on the emergency department triage record or the medical record or on the Transfer to Acute Care/Speciality Facility Summary form.

4) Establish priority of care by acuity and assign to appropriate area of care. Consider the Emergency Medical Condition Policy, if indicated ...

6) Document triage priority category.

7) Document ongoing monitoring and disposition of patient...

B. Consent for screening and/or treatment may be implied if the patient is incapable of giving consent and no representative is available or any delay to obtain consent would jeopardize the patient's safety.

If a patient or a person acting on the individual's behalf refuses to consent to the medical screening exam or treatment:

1) Inform the patient or person acting on the individual's behalf of risks of refusal of the proposed examination or treatment and of the potential benefits.

2) Document steps taken to secure written refusal in the medical record or on the Against Medical Advice (AMA) form or on the Transfer to Acute Care/Speciality Facility Summary form. Obtain signature of patient or representative, if applicable. If patient or person acting on behalf of the individual refuses to sign, document refusal in the medical record.

3) In the event the patient has not been registered, document the patient's visit and disposition on the centralized log in the emergency department.

4) A patient who has refused the screening or treatment may be released.


2. Emergency Medical Condition Assessment Policy:
Emergency medical conditions are those manifesting themselves by acute symptoms of sufficient severity including severe pain, psychiatric disturbances, symptoms of substance abuse, and/or women in labor such that the absence of immediate medical attention could reasonable be expected to result in:

1) Placing the health of the individual in serious jeopardy ...

Procedure if an emergency medical condition exists:
1) Personnel should immediately begin stabilizing measures.

2) Emergency medical conditions must be stabilized within the capabilities of the hospital ...

5) Consent for screening and/or treatment may be implied if the patient is incapable of giving consent and no representative is available or any delay to obtain consent would jeopardize the patient's safety.

6) If a patient or person acting on the individual's behalf refuses to consent to the medical screening exam or treatment:

a. Inform the patient or person acting on the individual's behalf of the risks of refusal of the proposed examination or treatment and of the potential benefits.

b. If the patient is unstable, attempt to have the physician complete the Informed Consent for Transfer to Acute/Care Speciality form ...

3. Against Medical Advice (AMA) Discharge
Purpose: To establish a process for documentation of patients leaving against medical advice.
Policy: The appropriate "Release from Responsibility for Leaving Against Medical Advice" form shall be completed when a patient insists upon leaving the hospital against medical advice (AMA). The form should be signed by the patient or the patient's representative if the patient is a minor or otherwise legally incapacitated and witnessed by two staff members. This form shall remain in the medical records. Refer to the hospital policy on consent to determine who is an appropriate patient representative for a minor or otherwise legally incapacitated patient.

Procedure:
1. Assess the patient's current condition and the rationale for wanting to leave AMA. Notify the Manage, Director or House Supervisor to assess the patient and situation.

2. Attempts should be made to intervene as appropriate to prevent the patient from leaving AMA (such as having the attending physician talk with the patient, or the patient's representative, via phone or in person).

3. Notify the attending physician if the patient insists upon leaving the hospital AMA ...

4. Document in the focus notes the patient interactions, interventions by staff, and the attending physician's response to the patient's request to leave the hospital AMA and discussions with the patient.

Hospital # 2's Medical Staff Rules and Regulations adopted by the Medical Executive Committee on November 12, 2012 and approved by the Mobile Infirmary Association Board on December 13, 2010 revealed the following:

Article X Emergency Services 10.2 Medical Screening Examinations:
(a) Medical screening examinations, within the capability of the Medical Center, will be performed on all individuals who come to the Medical Center requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who can perform medical screening examinations within applicable Medical Center policies and procedures are defined as:

(1) Emergency Department:
(i) members of the Medical Staff with clinical privileges in Emergency Medicine;
(ii) other Medical Staff members; and
(iii) appropriately credentialed allied health professionals ...

Hospital 2's Action Plan: (Received via email on 6/27/13)
A. In April 2013 a Performance Improvement project to decrease Left Without Being Seen (LWBS) rates, decrease door to physician time and decrease Length of Stay (LOS) for patients discharged from the Emergency Department (ED) was initiated. These actions included:
1. Placing an RN in the waiting room to assign an initial triage level for patients arriving between 10:00 AM and 10:00 PM.
2. Assign a Nurse Practitioner to the Triage area to perform Medical Screening Exams (MSE), treat and discharge lower acuity patients...
3. In July and August, Security, ED staff and physicians will be re-educated regarding EMTALA law and care of LWBS and disruptive patients, Communication, Chain of Command and Core values of Mobile Infirmary.
4. An intense Analysis was completed regarding both incidents.

Based on interviews, review of medical records, Emergency Medical Services (EMS) reports and Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures, it was determined Hospital 2 failed to provide stabilizing treatment for Patient Identifier (PI) # 1 and PI # 2, two of 29 sampled patients who presented to Hospital 2's Emergency Department (ED).

This deficient practice negatively effected Patient Identifier (PI) # 1, a patient who was returned to Hospital 2's ED on 5/27/13 by a responsible representative who notified ED staff that something was wrong with PI #1. The deficient practice also negatively effected PI # 2, a patient who presented to the ED via ambulance on 3/5/13 with a chief complaint of weakness and altered mental status. PI # 2 reportedly acted aggressively, refused triage and laid down on the floor. ED Clinical staff failed to evaluate PI # 2's behavior to determine if the behavior was related to a emergency medical condition. Clinical staff reportedly observed PI # 2's behavior and observed the placement of PI # 2 in a wheelchair by security staff. PI # 2 was then transported off Hospital 2's property.

This deficient practice had the potential to negatively effect all patients who present to Hospital # 2's ED with a emergency medical condition and require stabilizing treatment.

Findings include:

Review of PI # 1's medical record dated 5/27/2013 from Hospital 2 revealed the following:

Patient arrived in ED at 04:20 AM.

Triage began at 04:30 AM. The following documentation was included in the Triage notes:

04:34:12 - Pt c/o (complained of) SOB (shortness of breath) with occas. (occasional) CP (Chest pain) on & off for the last month. Worse tonight, "I feel like I can't catch my breath." Some n/v (nausea/vomiting) when pain is worst.

04:38:33 Patient was taken to ED room 24.

04:54:24 the nurse documented, "Awaiting MD (Medical Doctor) eval (evaluation)."

06:34 AM - EI # 5, ED physician documented, "This case is a certified medical emergency ..."

06:46:22 EI # 8, RN documented, "... RN went to pts (patient's) room. Pt asked to see (doctor) RN asked what this was concerning and pt became belligerent. Pt was not in stretcher, did not have O2 on, and began cursing @ RN. RN explained to pt that need to be in bed with O2 on. Security called. Pt wants to leave ama (against medical advice). EI # 8, ED physician informed. Pt informed of risks of leaving ama. Pt refused to sign AMA form. Pt removed own IV would not allow (nurse) to apply gauze. Pt states, "You can't keep me here, I am not under arrest". Pt walked to truck by own power with security. Threatening security along the way ..."

06:48:58 - ED disposition set to eloped as documented by EI # 5, ED physician.

06:49 - EI # 5, ED physician documented, ED Course/Plan, "... Chest pain: SOB (Shortness of breath) Diagnosis management comments: The patient became hostile and belligerent and had to be removed from the emergency department prior to my evaluation. I did not lay eyes on this patient ... Patient Progress: stable ..."

Interview with Employee Identifier (EI) # 8, Staff RN ED at Hospital 2, 0630 - 1830 shift, on 6/26/13 at 10:50 AM:


Relationship to PI #1: RN assigned to PI # 1 when patient left Against Medical Advice (AMA).


Sometime around 0630 on 5/27/2013, EI # 8 said he was notified that PI # 1 wanted to see the doctor. EI # 8 went into PI # 1's room. According to EI # 8, PI # 1 was cursing, yelling and hostile. PI # 1 stated he was hurting, had completed multiple tests and wanted to leave. The RN (EI # 8) said he explained to PI #1, the "MD (Medical Doctor) has to see you." Security was called. PI # 1 said, "You can't keep me here." The RN said he reviewed the AMA form with PI #1, but the patient refused to sign the form. PI # 1 pulled out his IV and was bleeding on the floor.


According to EI # 8, the RN notified the physician "as a courtesy" that PI # 1 wanted to leave AMA. EI # 8 indicated there was not enough time for the physician to see PI #1, once PI # 1 decided to leave AMA. EI # 8 said PI # 1's departure was, "Not really an AMA," but staff still attempts to get the AMA form signed by the patient. According to EI # 8, Hospital 2 does not have an elopement form. The ED Physician reportedly said, "O.K. I haven't even seen him." According to EI # 8, PI # 1's request to leave was abrupt. While walking out of the ED, PI # 1 was "loud and belligerent."
PI # 1 said, "You can't keep me here."


Minutes later, the ED Liaison (admitting clerk), informed the charge nurse that PI # 1 was reportedly seizing in the ambulance bay. According to the RN, as he and the ED Charge Nurse arrived at the ambulance bay doors, a truck allegedly containing PI # 1, was driving off. The RN could not see the driver or the patient. Later, (time unknown) Hospital 2's ED received a call from Hospital 1's ED asking for PI # 1's history. Hospital 1 reported staff had, "Just pulled PI # 1 out of the truck." The RN said he was informed PI # 1 died.


Review of Patient Identifier (PI) # 1's medical records from Hospital # 1 dated 5/27/2013 revealed PI # 1 returned to Hospital # 1's ED at 07:03 AM by private vehicle.

Review of the Medical Screening/Nursing Assessment revealed the patient's chief complaint was Cardiac Arrest ... possible seizure, CPR (cardiopulmonary resuscitation) PI# 1's primary assessment revealed the patient was unresponsive...skin was warm and dry with no movement.

Further documentation revealed, "... 35 yom (year old male) presents to ED, POV (privately owned vehicle) for possible seizure ... pt was found to be pulseless and apneic. CPR initiated. Pt taken to TR (Trauma Room) with CPR cont. (continued). 7.0 ETT (endotracheal tube) placed & confirmed with ... BBS (bilateral breath sounds). No epigastric gurgling ... ACLS (Advanced Cardiac Life Support) ... Pt defibrillated ... firing for VF (ventricular fibrillation) with no response except asystole. Heroic measures performed. CPR and defib ... No signs of life... Asystole... pt had been at (Hospital # 2) PTA (prior to arrival) ..." PI # 1's time of death was documented as 07:22 AM.

Interview with EI # 5, MD, ED Physician at Hospital 2, 0600 - 1830 Shift, on 6/25/13 at 8:14 PM:

Relationship to PI # 1: ER Physician on 5/27/13 when PI # 1 left AMA.

The physician was asked if he recalled PI # 1 and he responded," No, I never laid eyes on him." The patient (PI # 1) had already gone when I got ready to see him." When asked if anyone told him about PI # 1, EI # 5 said, "They told me generically that the patient (PI #1) was in the room. I said...I'll get around to him."

EI # 5 verified he documented PI # 1's visit on 5/27/2013 was a certified medical emergency in PI # 1's medical record. According to EI # 5, he based this decision on a lay person's definition of an emergency. "If a patient shows up. A lay person would consider the patient's presentation to the Emergency Room an emergency." EI # 5 said he documents every patient who presents to the ED is a certified medical emergency. EI # 5 was advised his documentation in the medical record revealed PI # 1 was stable at discharge. EI # 5 (Physician) was asked to explain how he determined the patient was stable, if he did not assess PI # 1. EI # 5 said, "I assume if the patient (PI # 1) left on his own power the patient was stable."


Interview with EI # 6, Protective Services Officer at Hospital 2, 0630 to 1830 Shift, on 6/26/13 at 1:08 PM:

Relationship to PI # 1: Conversation with responsible person (driver) who accompanied PI # 1 to Hospital 2's ED on 5/27/13.

EI # 6 said when he began the day shift, he was informed by the Protective Services night shift Team Leader that PI # 1 had been removed from the ED due to aggressive behavior and cursing staff. He reported he was advised PI # 1 and the female accompanying PI # 1 had been asked to leave the hospital.

According to EI # 6, a truck pulled in and parked in the ambulance bay. EI # 6 said a female was standing outside of the truck. The officer said to the female, "Ya'll have been asked to leave the property." The female reportedly said, "I don't know what to do." According to the EI # 6, the female did not say anything about PI # 1. The officer stated he said, " I don't know, but you were asked to leave here." The female returned to the truck and pulled away. EI # 6 was asked if ED staff were present in the ambulance bay. EI # 6 said, "No. They (staff) came out as the truck was pulling away."


Interview with EI # 4, RN, Day shift ED Charge Nurse at Hospital 2, on 6/25/13 at 4:57 PM:

Relationship to PI # 1: Charge Nurse when PI # 1 arrived Hospital 2's ED on 5/27/13:

EI # 4 stated she was asked by the RN assigned to PI #1 to get security because PI # 1 was irate, belligerent and wants to leave. EI # 4 said she saw a security guard and PI # 1 walking out of the ED. Shortly after PI # 1 left the ED, the ED Liaison came to me and said PI # 1 is back. EI # 4 said she and a staff RN went to the ambulance bay just as the female was driving the truck away from the bay area. "I never saw the patient (PI #1) after he walked out with the security guard." ED staff from Hospital 1 called to, "Let us know the patient (PI # 1) was there." EI # 4 was asked if PI # 1 was seen/evaluated by the ED physician at Hospital 2 and she said, No."


Interview with EI # 9, ED Liaison Hospital 2, on 6/26/2013 at 3:30 PM:

EI # 9 stated the ED Charge Nurse came to the waiting area on 5/27/13 to obtain assistance from the security officer to, "Make this patient (PI # 1) leave because he was cursing all of the nurses." From a monitor at the registration desk in Hospital 2's waiting area, EI # 9 said she could see
PI # 1 and staff walking outside in the ambulance bay. Although there is no audio monitoring, EI # 9 said she could hear PI # 1 and staff talking when they were in the ambulance bay when the automatic doors opened. According to EI # 9, she heard PI # 1 say, "This is not right. Why are ya'll making me leave. I'm sick." PI # 1 got in a truck and left the ED.


"A few minutes later a female driver pulls into the ambulance bay, walks into Hospital 2's ED waiting area and says her boyfriend is having a seizure or something. They just made us leave." EI # 9 said she went into the ED (patient treatment area) and advised a staff RN about the female's complaint. EI #9 alleged the staff RN said, "We're not going to get him (PI # 1) out of the truck. We don't do that." EI # 9 said she then advised the ED Charge Nurse of the situation. According to EI # 9, the Charge Nurse told the staff RN to accompany her to the ambulance bay to check on the patient (PI # 1).



2. EMS Transport of PI # 2 to Hospital 2:
Review of the Ambulance Patient Care report dated 3/5/13 revealed PI # 2's chief complaint was weakness and AMS (altered mental status)... Arrived at destination (Hospital 2).

Review of the electronic copy of the EMS (Emergency Medical Services) report revealed the patient's assessment included, "... Pt was transported Code 1 to MIMC (Hospital 2) .. waiting rm (room) with the following incident: After obtaining wheelchair and attempting to assist pt from stretcher to the wheelchair (via stand & pivot) Pt repeatedly refused attempts to get off of the stretcher. Pt pushed attendant 1 away twice, and the second time, Pt picked his legs back up on the stretcher, curling his legs up, Lying back and appearing to take a nap. At this point, ER (Emergency Room) Charge RN (Registered Nurse) attempted to verbally motivate pt to get off the stretcher without success. Ultimately, MIMC (Hospital # 2) ... Security Officer (An off duty Mobile Police Officer) had to physically remove pt from the stretcher, Though pt did not suffer any apparent injuries in this process. Pt was wheeled to waiting rm and checked in (with admissions) with transfer of care, written & verbal report to ER triage RN..."

Review of Patient Identifier (PI) # 2's medical record from Hospital # 2 revealed the patient presented to Hospital # 2's ED on 3/5/13 at 9:00 PM by ambulance with weakness and nausea. EI # 15, Triage RN, documented PI # 2's disposition at 2212 (10:12 PM) was AMA/LWBS (Against medical advice/Left without being seen) before triage.

Review of the Fire-Rescue Field Triage Sheet dated 3/6/13 revealed the incident location was documented as "Dead end Center St at (Hospital # 2) ..." The Fire-Rescue staff member documented, "... Pt was kicked out of (Hospital # 2) at 2200 per (Hospital # 2) staff. Vitals taken ... (Ambulance company name) ..." (See EMS Report # 2 below)

Review of EMS Report # 2 revealed a call was received at 02:07 AM on 3/6/13 for "One Down" (person down on the ground). EMS arrived at the location and found PI # 2 on the ground for "4 hours" after security told to leave (Hospital # 2) ... Pt has weakness and AMS (altered mental status). Pt would not speak. Pt skin very cold. Pt unknown for any other complaints ... Pt given supportive care ... Pt moved to stretcher ...Pt transported to (Hospital 3)..."

Review of PI # 2's medical record from Hospital 3:
Emergency Department ER (Emergency Room) Nursing Triage Note on 3/6/13 at 02:47 AM revealed the patient's Chief complaint included, "... This 24 year old male patient admitted with chief complaint of pt picked up outside (Hospital 2) laying on the ground for the past several hours. EMS says pt was brought to (Hospital 2) around 2200 last night for AMS but was not seen bc (because) he was thrown out for misbehaving ..."
The patient's vital signs were documented: Temperature 94.7 rectally, blood pressure 119/93, heart rate 146, and respiration 24. The Triage nurse documented the patient was unable to communicate pain level, opened eyes spontaneously, withdraws from painful stimuli with no verbal response. The Triage nurse documented the patient's physical assessment revealed the patient's skin turgor was good, normal and cool, the patient was alert and oriented times 3 and there was no verbal response.

The patient was admitted to room 5 via stretcher per EMS and connected to a monitor. The ED physician was at the bedside.

Review of the ED physician's Note dated 3/6/13 at 03:36 AM revealed the patient's chief complaint was decreased responsiveness. The ED physician documented, "EMS provides history. This 24 year old male patient presents with moderate gradual worsening decreased responsiveness beginning several hours prior to arrival. Pt picked up outside (Hospital # 2) laying on the ground for the past several hours. EMS says pt was brought to (Hospital # 2) around 2200 last night for AMS but was not seen bc (because) he was thrown out for misbehaving. apparently he has been non-compliant with meds (medications) and hasn't been seen for a few days. Pt unable to provide any history ..."

Review of the ED physician's Note revealed PI # 2's physical examination revealed the patient was well developed, well nourished and nontoxic appearance with a fruity odor to breath. PI # 2's heart rate was regular and lungs were clear bilaterally.

The following tests were ordered with their abnormal findings:
Blood gases:
PCO2 (Partial pressure of Carbon Dioxide) (reflects the amount of Carbon Dioxide dissolved in the blood) = 25.6 (low)
PO2 (Partial Pressure of Oxygen) (amount of Oxygen dissolved in the blood) = 123 (high)
Base Deficit: (quantitative measure of the body's effort to neutralize acids in the blood stream) = 11 (high)
HCO3 (Bicarbonate) (neutralizes acids in the blood stream) = 14.2 (low)
TCO2 (Total Carbon Dioxide content) = 15 (low)
O2 Sat calculated (Oxygen saturation) (measures the percent of hemoglobin which is fully combined with Oxygen = 99 (high)

Hematology:
WBC (White blood count) = 10.7 (high)
RBC (Red blood count) = 3.40 (low)
Hemoglobin = 8.5 (low)
Hematocrit = 25.4 (low)

Urinalysis:
Protein = 3+ (high)
Urine RBC's = >100
Urine Bacteria = 4+

Basic Metabolic Panel:
Sodium = 133 (low)
Chloride = 92 (low)
CO2 (Carbon dioxide) = 13 (low)
BUN (Blood urea nitrogen) (one of the measures of kidney function) = 135 (high)
Creatine (a measures of kidney function) = 10.58 (high)
CPK (Creatine phosphokinase) (a measure of possible injury or stress to muscle tissue, heart or brain) = 945 (high)

Troponin I (measures the amount of proteins Troponin I and Troponin T, which are released in the blood stream when there is heart muscle damage) = 0.119 (Intermediate for myocardial injury)

Radiology findings: Chest X-ray - No acute abnormality and CT (Computerized tomography) head - no acute hemorrhage or mass effect.

The ED physician documented the diagnostic impression of PI # 2 was altered mental status and anion-gap acidosis. PI # 2's final disposition was transferred to ICU (Intensive Care Unit) of Hospital #3.


Interview with EI # 11, RN ED Charge Nurse at Hospital 2, on 6/26/13 at 10:00 AM.

Relationship to PI # 2: Charge Nurse when PI # 2 presented to the ED on 3/5/13.

EI # 11 stated PI # 2 arrived via EMS at Hospital 2 on 3/5/13. EI # 11 directed EMS staff to take PI # to triage. EI # 11 was asked to identify the criteria used to determine PI #2 's appropriateness for triage versus direct placement in an ED bed.


EI # 11 verified the criteria as PI # 2 's complaint of weakness, noncompliance with medications per EMS staff, PI # 2's age and vital signs. EI # 11 said PI # 2 did not want to get off of the stretcher and into a wheelchair, but was eventually compliant without assistance. EI # 11 said she was advised PI #2 did not want to be treated and "walked off."
EI # 11 stated she was informed PI # 2 told the triage nurse, "Get your "f....g hands off me." The only information documented in PI # 2's medical record on 3/5/13 includes, "2100: Arrived ED. 22:12: AMA/LWBS - LWBS (Left Without Being Seen) before triage. 22:13: Pt. (patient) dismissed."



Interview with EI # 12, ED Staff RN Hospital 2, on 6/26/13 at 9:25 AM:

According to EI # 12, the Charge Nurse directed PI # 1 to triage after PI # 2 arrived in the ED via ambulance. EI #12 reported seeing EMS staff and hospital security attempting to move PI #2 from a stretcher to a wheelchair. EI # 12 described the patient as "kind of combative." "He (PI # 2 ) was sitting up and all of a sudden refused to do anything."


Interview with ED Admission Assistant at Hospital 2, EI # 13, on 6/26/13 at 2:20 PM:


EI # 13 stated she was asked by a paramedic on 3/5/13 to notify security was needed because PI # 2 was refusing to get off a stretcher and into a wheelchair after his arrival via ambulance at Hospital 2's ED. PI # 2 was assisted to a wheelchair and brought to the ED waiting area. PI # 2 was taken to the triage room. EI # 13 reports she heard screaming. PI # 2 was out of the wheelchair and saying he did not want to be seen. EI # 13 reports PI # 2 was walking as he was escorted by a security officer out of the triage room.



Interview with EI # 14, Director Protective Services at Hospital 2, on 6/25/13 at 2:36 PM:

According to EI # 14, PI # 2 had been disruptive and non-compliant in the triage area. PI # 2, "Went to the ground" at the ambulance bay doors when exiting the ED on 3/5/13. PI # 2 was put in a wheelchair and escorted off hospital property by a security officer no longer employed by Hospital 2.



Review of Hospital # 2's Policy and Procedures revealed:


Policy Title: Emergency Medical Condition Assessment Policy

Emergency medical conditions are those manifesting themselves by acute symptoms of sufficient severity including severe pain, psychiatric disturbances, symptoms of substance abuse, and/or women in labor such that the absence of immediate medical attention could reasonable be expected to result in:

1) Placing the health of the individual in serious jeopardy ...

Procedure if an emergency medical condition exists:

1) Personnel should immediately begin stabilizing measures.

2) Emergency medical conditions must be stabilized within the capabilities of the hospital ...

5) Consent for screening and/or treatment may be implied if the patient is incapable of giving consent and no representative is available or any delay to obtain consent would jeopardize the patient's safety.

6) If a patient or person acting on the individual's behalf refuses to consent to the medical screening exam or treatment:

a. Inform the patient or person acting on the individual's behalf of the risks of refusal of the proposed examination or treatment and of the potential benefits.

b. If the patient is unstable, attempt to have the physician complete the Informed Consent for Transfer to Acute/Care Speciality form ...

The hospital failed to ensure that their policies were followed as evidenced by failing to ensure that patients presenting to the Emergency Department manifesting themselves by acute symptoms receive immediate stabilizing treatment and must be stabilized within the capabilities of the hospital. Patient # 1 presented to the ED on 5/27/2013 on his second visit with a complaint of seizure (manifestation of an acute symptom) as stated by his/her representative, seeking medical care for an identified emergency medical condition, as identified and verified by Hospital # 3. Patient # 2 was picked up by EMS at his residence on 3/5/2013 with a complaint of weakness with altered mental status (manifestation of an acute symptom). The patient responded to verbal stimuli, but was not alert and oriented times 2 only (manifestation of an acute symptom). A review of Mobile Infirmary's medical record reveals the arrival complaint, in part, as "weakness" (manifestation of an acute symptom). The hospital failed to ensure that stabilizing treatment was provided as required to stabilize the medical condition fro Patient #1 and Patient #2.

Based on interviews, medical record reviews, review of Emergency Medical Treatment and Labor Act (EMTALA) Policies and Procedures and review of the hospital's security video, Hospital 2 failed to provide appropriate medical screening examinations and stabilizing treatment resulting in inappropriate transfers of Patient Identifier (PI) # 1 and PI # 2. The hospital also inappropriately discharged an unstable patient, PI # 2. This affected two of 29 sampled patients who presented to Hospital 2's Emergency Department (ED). This deficient practice has the potential to effect all patients who present to Hospital 2's ED.
Findings include:
Review of PI # 1's medical record dated 5/27/2013 from Hospital # 2 revealed the following:
Patient arrived in ED at 04:20 AM.
Triage began at 04:30 AM. The following documentation was included in the Triage notes:
04:34:12 - Pt c/o (complained of) SOB (shortness of breath) with occas. (occasional) CP (Chest pain) on & off for the last month. Worse tonight, "I feel like I can't catch my breath". Some n/v (nausea/vomiting) when pain is worst.
04:38:33 Patient was taken to ED room 24.
04:54:24 the nurse documented, "Awaiting MD (Medical Doctor) eval (evaluation)."
06:34 AM - EI # 5, ED physician documented, "This case is a certified medical emergency ..."
06:46:22 - EI # 8, RN documented, "... RN went to pts (patient's) room. Pt asked to see (doctor)- RN asked what this was concerning and pt became belligerent... Security called. Pt wants to leave ama (against medical advice). EI # 5, ED physician informed. Pt informed of risks of leaving ama. Pt refused to sign AMA form... Pt states, "You can't keep me here, I am not under arrest... Pt walked to truck by own power with security. Threatening security along the way ..."
06:48:58 - ED disposition set to eloped documented by EI # 5, ED physician.
06:49 - EI # 5 documented, "... Chest pain: SOB (Shortness of breath)... The patient became hostile and belligerent and had to be removed from the emergency department prior to my evaluation. I did not lay eyes on this patient ... Patient Progress: stable ..."

Review of Patient Identifier (PI) # 1's medical records dated 5/27/2013 from Hospital # 1 revealed PI # 1 returned to Hospital # 1's ED at 07:03 AM by private vehicle.
Review of the Medical Screening/Nursing Assessment revealed the patient's chief complaint was Cardiac Arrest ... possible seizure...PI# 1's primary assessment revealed the patient was unresponsive... skin was warm and dry ...no movement.

Further documentation revealed, "... 35 yom (year old male) presents to ED, POV (privately owned vehicle) for possible seizure ... pt was found to be pulse less and apneic. CPR initiated. Pt taken to TR (Trauma Room) with CPR cont. (continued) 7.0 ETT (endotracheal tube) placed & confirmed with ... BBS (bilateral breath sounds) (no) epigastric gurgling ... ACLS (Advanced Cardiac Life Support) ... Pt defibrillated ... firing for VF (ventricular fibrillation) with no response except asystole. Heroic measures performed. CPR and defib ... No signs of life. Unable to gain ... Asystole... pt had been at (Hospital # 2) PTA (prior to arrival) ..." PI # 1's time of death was documented as 07:22 AM.

Hospital 2 failed to provide a medical screening examination and stabilizing treatment for PI # 1 upon his return to Hospital 2's ED, which ultimately resulted in the responsible representative transporting PI # 1 to Hospital 1 via private car. Hospital 2's failure to provide medical screening examination and stabilizing treatment resulted in an inappropriate transfer to Hospital 1.

2. Review of the Ambulance Patient Care report dated 3/5/13 revealed PI # 2's chief complaint was weakness and AMS (altered mental status)... Arrived at destination (Hospital # 2) at 20:45.

Review of Patient Identifier (PI) # 2's medical record from Hospital 2 revealed the patient presented to Hospital 2's ED on 3/5/13 at 9:00 PM by ambulance with weakness and altered mental status. EI # 15, Triage RN, documented PI # 2's disposition at 2212 (10:12 PM) was AMA/LWBS (Against medical advice/Left without being seen) before triage.

During a review of the hospital's security tape, (dated 3/15/2013), the patient was seen lying on the floor between the ED and the ambulance bay. A security officer picked up the patient and placed him in a wheelchair. Next, the officer was seen pushing the wheelchair in the driveway of the ambulance bay away from the Emergency Department. During an interview with EI # 4 on 6/25/13 at 2:36 PM, the Director Protective Services, said the officer transported the patient (PI # 2) off hospital property.

Review of EMS Report # 2 revealed a call was received at 02:07 AM on 3/6/13 for "One Down" (person down on the ground). EMS arrived at the location and found PI # 2 on the ground for "4 hours" after security told to leave (Hospital # 2) ... Pt has weakness and AMS (altered mental status). Pt would not speak. Pt skin very cold. Pt unknown for any other complaints ... Pt given supportive care ... Pt moved to stretcher ... Pt transported to (Hospital # 3)..."

Review of PI # 2's medical record from Hospital # 3:
Emergency Department ER (Emergency Room) Nursing Triage Note on 3/6/13 at 02:47 AM revealed the patient's Chief Complaint included, "... This 24 year old male patient admitted with chief complaint of pt picked up outside (Hospital # 2) laying on the ground for the past several hours. EMS says pt was brought to (Hospital # 2) around 2200 last night for AMS but was not seen bc (because) he was thrown out for misbehaving ..."

Review of the ED physician's Note dated 3/6/13 at 03:36 AM revealed the patient's chief complaint was decreased responsiveness. The ED physician documented, "EMS provides history. This 24 year old Male patient presents with moderate gradual worsening decreased responsiveness beginning several hours prior to arrival. Pt picked up outside (Hospital # 2) laying on the ground for the past several hours. EMS says pt was brought to (Hospital # 2) around 2200 last night for AMS but was not seen bc (because) he was thrown out for misbehaving. apparently he has been non-compliant with meds (medications) and hasn't been seen for a few days. Pt unable to provide any history ..."

The ED physician documented the diagnostic impression of PI # 2 was altered mental status and anion-gap acidosis (increase in plasma acidity). PI # 2's final disposition was transferred to ICU (Intensive Care Unit) of Hospital # 3. The patient expired on 3/18/2013. The hospital discharged Patient # 2, which was an inappropriate discharge of an unstable patient who was manifesting acute symptoms of altered mental status. The hospital failed to provide a Medical Screening Examination (MSE) to determine whether or not an emergency condition existed, failed to provide stabilizing treatment prior to discharging / dumping Patient #2 out of a wheelchair, off of hospital property on 3/5/2013.

Hospital # 2's Policy and Procedure:

Transfer/Discharge of Unstabilized patient to another acute care/specialty facility

An appropriate transfer of an unsteadied patient may occur only when the patient (or responsible person acting on the individual's behalf) is informed of hospital's obligation to provide stabilizing treatment and informed of the medical risks and benefits of transfer. The Transfer to Acute Care/Speciality Facility Summary form is completed to document the communication of the hospital' s obligation, explanation of risks and benefits for transfer and the reason for the request to transfer ...

Transfer/Discharge of an unstabilized patient to another acute care/speciality facility procedure.

1) Reason for transfer is to be documented on the Transfer to Acute/Speciality Facility Summary Form, selecting from the following:

a. The patient (or responsible person acting on the individual's behalf) requests the transfer to another facility.

b. Physician determines that transfer benefits outweigh risks.

c. Patient requires services and facility lacks current capacity as determined by Administration. (i.e. cath lab full, no ICU beds)

I. THE PHYSICIAN CERTIFIES IN WRITING THE SUMMARY OF RISKS AND BENEFITS OF TRANSFER.

Have the physician complete the summary of risks and benefits of transfer on the Informed Consent for Transfer to Acute Care/Speciality Facility form.

II. CONTINUE TO PROVIDE MEDICAL TREATMENT WITHIN THE HOSPITAL'S CAPACITY THAT MINIMIZES THE RISKS TO THE INDIVIDUAL'S HEALTH AND, IN THE CASE OF A WOMAN IN LABOR, THE HEALTH OF THE UNBORN CHILD.

III. CALL THE RECEIVING FACILITY FOR APPROVAL TO TRANSFER.

The receiving facility must have available space and qualified personnel for the treatment of the patient and must agree to accept the transfer. Document on the Transfer to Acute Care/Speciality Facility Summary form the communication with the receiving facility including the name and title of the person accepting the transfer.

IV. THE TREATING PHYSICIAN IS RESPONSIBLE FOR ARRANGING FOR A PHYSICIAN TO ACCEPT THE PATIENT AT THE RECEIVING FACILITY.

V. ARRANGE FOR TRANSPORT OF THE PATIENT ...

VI. SEND ALL MEDICAL RECORDS RELATING TO THE EMERGENCY MEDICAL CONDITION WITH THE PATIENT ...

VII. FULLY COMPLETE THE TRANSFER TO ACUTE CARE/SPECIALITY FACILITY SUMMARY FORM AND ATTACH THE PHYSICIAN ' S COMPLETED INFORMED CONSENT FOR TRANSFER OR REFUSAL TO ACUTE CARE/SPECIALITY FACILITY FORM, if applicable.

Send the original with patient and retain the copy for the medical record. Consent for screening and/or treatment may be implied if the patient is incapable of giving consent and no representative is available or any delay to obtain consent would jeopardize the patient's safety.

VIII. DOCUMENT PATIENT'S INFORMED DECISION REGARDING TRANSFER/DISCHARGE OR REFUSAL FOR TREATMENT.

A. If the benefits of transfer outweigh the risks and the patient or person acting on his behalf refuses to transfer, inform the patient or person acting on his behalf of the risks and benefits of the transfer. Take all reasonable steps to secure the individual's (or that of a person acting on his or her behalf) written refusal in the applicable section of the Transfer to Acute Care/Speciality Facility Summary. The document must reflect that the risks and benefits to transfer were explained and the reasons for refusal. If the patient is unstable, have the physician complete the Informed Consent for Transfer to Acute/Care Speciality form.

B. If the patient requests transfer to another facility and the risks of transfer outweigh the benefits, inform the patient or person acting on his behalf of the risks and benefits of the transfer. Take all reasonable steps to secure the individual's (or that of a person acting on his or her behalf) written request for transfer on the Transfer to Acute/Care Speciality Facility Summary form. The documentation must reflect that the risks and benefits to transfer were explained and the reasons for refusal. If the patient is instable, have the physician complete the Inform Consent for Transfer to Acute/Care Speciality form.

C. If patient or person acting on his or her behalf refuses to sign follow the above procedures for Appropriate Transfer/Discharge of and Unstabilized Patient to Another Acute/Care Speciality Facility.

D. Record final disposition.


Hospital # 2 failed to follow their EMTALA policy and procedure as it relates to the appropriate transfer of PI # 1 on 5/27/13 to Hospital # 1 and
the inappropriate discharge of an unstable patient (PI # 2) on 3/5/13 to Hospital #3. Hospital 2 failed to:

1. Provide an appropriate medical screening exam and stabilizing treatment, which the facility had the capacity and capability to perform.

2. Arrange for receiving physicians at Hospitals 1 and 3 to accept care of PI # 1 and PI # 2.

3. Provide and complete an informed consent for transfers for PI # 1 and PI # 2.

4. Supply Hospitals 1 and 3 with a copy of the medical record for PI # 1 and PI # 2.

5. Record the final dispositions of PI # 1 and PI # 2.


PI # 1 and PI # 2 were inappropriately transferred/discharged from Hospital 2 to Hospitals 1 and 3 due to Hospital 2's failure to provide appropriate medical screening examinations and stabilizing treatment, which Hospital 2 had the capacity and capability to perform to minimize the risks to these patients' health on 3/5/2013 and 5/27/2013.