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Based on interview and record review of Emergency Department (ED) logs, medical records, staffing and physician on-call schedules, the facility failed to provide an appropriate and thorough medical screening examination for one patient (#25) of 26 patient's records reviewed. The facility's failure to provide an appropriate and sufficient medical screening examination delayed the recognition of a psychiatric emergency medical condition and resulted in delayed treatment. The average ED monthly census over the past six months was 896. The facility census was 10.


Refer to A2406 for details.

Based on interview, record review, and policy review, the facility failed to provide a Medical Screening Examination (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) within the facility's capacity and capability for one patient (#25) of 26 Emergency Department (ED) patient records reviewed. This had the potential to affect all patients who presented to the ED. The average monthly census over the past six months was 896. The facility census was 10.
Findings included:

1. Record review of the facility's policy titled, "EMTALA - Medical Screening Examination," dated 04/2015 showed the following:

- The purpose was to ensure that each individual who comes to the ED received an appropriate medical screening examination or "MSE" as required by federal law.
- The hospital shall provide each individual who comes to the dedicated ED with an appropriate MSE within its capabilities to determine whether the individual has an emergency medical condition.
- The hospital shall provide a MSE by a Qualified Medical Provider (QMP) to each individual who comes to the hospital's dedicated ED without a scheduled appointment or intended visit and requests examination or treatment for a medical condition.

2. Record review of the ED Nursing Assessment Flowsheet performed by Staff G, Licensed Practical Nurse, (LPN), on 12/25/16 at 10:23 PM showed:

- The patient was brought into the facility by the police department for "Fit for Confinement" (medical clearance before going to jail) exam.
- Patient's mother stated that she believed the patient had overdosed on methadone (a narcotic used to treat moderate to severe pain) but the patient denied taking anything and refused all interventions and assessment.
- The patient was breathing easy and was alert and oriented.

During a telephone interview on 01/04/17 at 8:30 AM, Staff G, LPN, stated that:

- The patient spoke only "when she wanted to";
- When the patient spoke, her speech was clear, understandable and appropriate to the question or situation;
- The patient's mother was concerned that the patient had overdosed;
- The patient refused to have her vital signs (temperature, blood pressure, heart rate and breathing rate) taken;
- The ED physician determined that the 26 year old patient was in no acute distress, was her own person (did not require a guardian) and was able to refuse assessment;
- The police attempted to convince the patient to tell the facility staff what she had taken or what was wrong so she could be treated as the warrants for her arrest could wait.

3. Review of the medical record indicated ED physician F documented on 12/25/16 at 10:25 PM the following:

- Chief complaint was "Fit for Confinement."
- The patient denied having taken any medications or drugs.
- The patient refused any medical treatment.
- The patient's mother stated that she could be withdrawing from drugs.
- No similar symptoms previously;
- The patient's gait was normal with handcuffs on, no tremors noted.
- The patient spoke in complete sentences, looked at each person as they talked and tracked conversation with her eyes;
- No laboratory testing or vital signs were obtained.
- Psychiatric exam showed the patient was oriented x 4 (to person, place, date and time), mood, affect (outward display of feelings or emotions) normal and memory intact; and
- ED physician F documented that she began her examination of patient #25 at 10:25 pm and 3 minutes later at 10:28 pm determined the patient was Fit for Confinement and ordered discharge. The evidence in the medical record indicated Fulton Medical Center did not provide an examination sufficient to determine if Patient #25 had an emergency medical condition, did not explain the risks of refusing examination and did not obtain the patient's signed informed refusal.

At 10:30 pm on 12/25/16, the ED physician documented on the "Prisoner Medical Clearance Report" that she examined the patient contrary to multiple entries in the medical record indicating the patient refused examination, and that law enforcement should "monitor (patient # 25) for signs of withdrawal." These failures resulted in a delay in patient # 25 receiving examination and treatment of an emergency medical condition.

During a telephone interview on 01/03/17 at 12:57 PM, Staff F, ED Physician stated that:

- Patient #25 presented to the ED on 12/25/16 for a Fit for Confinement exam;
- Patient's mother frequently repeated that she couldn't go to jail because she was withdrawing from taking drugs;
- At first the patient was completely non-verbal and only verbalized that she refused the exam;
- After the patient's mother continued to state that the patient had taken something the patient verbalized that she had not taken anything.
- Police informed the patient that the warrants out for her arrest were not a big deal and that if she had taken something she needed to tell the facility staff so that they could help her;
- The patient refused labs and vital signs;
- She did not consider that the patient was having psychiatric issues per her actions and general behavior; she was not "hypervigilant" as she sat on the end of the stretcher and was cooperative just verbalized refusal to parts of the exam;
- She wasn't informed of any previous psychiatric history by the patient or her mother;
- Even though the patient refused most of the exam she was still able to get clinical information by visually observing the patient; and
- She just thought it was potential drug withdrawal and not a psychotic episode at the time.

During a telephone interview on 01/03/17 at 4:08 PM, Staff H, ED Registration Clerk stated that:

- The patient's mom came into the facility to the registration desk and stated that she was worried her daughter had taken too much medication and that she wouldn't get out of the car to come in to be seen and asked for help to get her out of the car;
- Security was called and went out into the parking lot to attempt to help get the patient inside;
- The patient's mother called the local police to come and help;
- When the patient entered the facility she was in police custody and handcuffed; and
- When she went to obtain the patient's signature on the consent to treat the patient she was just starring off into space and was unable to sign it, the patient never refused to sign it "just wasn't able to."

5. During a telephone interview on 12/27/16 at 3:30 pm, an anonymous individual stated that patient #25 was not acting right, couldn't talk, was incoherent and acting very strange. When taken to Fulton Medical Center's ED on 12/25/16 around 10:07 pm, patient #25 would not get out of the car so police were called for assistance. The police took the patient into the ED to be examined. The patient would not communicate with the ED staff and the ED staff did not communicate with the anonymous individual who was also present in the ED. The anonymous individual stated the ED did not evaluate patient #25's vital signs or perform a neurological examination. The ED physician did not examine the patient. The anonymous individual stated the nurse in the ED told police patient #25 was "faking it" and she could go with the police to jail for an outstanding warrant.

6. Review of Patient #25's ED medical record from Hospital B showed:

- The patient presented to Hospital B's ED on 12/26/16 with a family member;
- The family member reported that patient # 25 had been very confused and nonverbal for the past three days and that she had been seen at Fulton Medical Center the day before and ended up in jail;
- The family member reported that patient # 25 had a history of alcohol abuse with possible liver damage, a history of bipolar 1 disorder (a type of bipolar disorder characterized by depressive and hypermanic [emotional state characterized by a distinct period of persistently elevated, expansive or irritable mood] episodes) with psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and had not been on medication for quite some time;
- Review of a previous admission and the discharge summary showed that the patient had received inpatient treatment at Hospital B approximately one year prior and that, "she had presented with the same symptoms as today's visit";
- The patient would not communicate with Hospital B's staff;
- The patient received a psychiatric evaluation because she exhibited a strange affect, would not answer questions, appeared to be very "spacey" and stared off [into space].
- The ED physician discussed the patient with Psychiatry and a decision was made to obtain a 96 hour hold to enable further evaluation by Psychiatry; and
- The patient was transferred to the psychiatric floor with a clinical impression of Psychosis, affective (a psychological reaction such as psychotic depression or mania in which the ego's functioning is impaired and there is loss of reality orientation).