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Based on review of the 4/10/2021 video recordings, review of medical records, review of Medical Staff Rules and Regulations, review of policies and procedures and interviews, it was determined that the facility failed to provide appropriate treatment within its capability and capacity for one (1) out of 20 sampled patients, Patient (P)#1, when P#1 presented to the Emergency Department on 4/10/2021 for complaints of 'hearing voices'.

Findings were:

Cross refer to A-2406, as it relates to the facility's failure to provide P#1 with an appropriate Medical Screening Examination.

Cross refer A-2407, as it relates to the facility's failure to provide P#1 with stabilizing treatment.

Based on review of the 4/10/2021 video recording, review of medical records, review of Medical Staff Rules and Regulations, review of policy and procedures and interviews, it was determined that the facility failed to provide an appropriate and ongoing medical screening exam for one of 20 patients (Patient #1) when Patient (P) #1 presented to the Emergency Department (ED) on 4/10/2021 for complaints of 'hearing voices'.

Findings:

A review of the ED video recordings for P#1 revealed the following:
First video: On 4/10/2021 (no time stamp), P#1 walked into the ED entrance alone and went to the registration desk. Per the time elapsed on the video recording, two minutes later a female family member entered, spoke with P#1 and sat down in the waiting room. RN AA spoke with P#1 at the registration desk and escorted him into triage room 1.
Second video: On 4/10/2021 (no time stamp) RN AA escorted P#1 to ED room 8. Per the time elapsed on the video recording, approximately one to two minutes later, RN AA exited ED room 8. At video elapsed time of 10 minutes 30 seconds, P#1's female family member entered ED room 8. At video elapsed time 13 minutes 15 seconds, a security officer walked down the hall. At video elapsed time 16 minutes 30 seconds, P#1's female family member exited ED room 8 and walked to the nurses' station across from ED room 8 and spoke with an unidentified nurse. A female family member paced in and out of ED room 8 at video elapsed time 17 minutes 30 seconds. At video elapsed time 17 minutes 50 seconds, P#1 exited ED room 8 and paced from the hallway to ED room 8 doorway continuously until he walked out of camera view at video elapsed time 20 minutes 52 seconds.
Third video: On 4/10/2021 (no time stamp) numerous staff members observed moving in and out of the trauma room. RN BB and other staff members are seen at the desk. At video elapsed time 2 minutes 30 seconds, P#1 walked down hallway and exited out the ambulance entrance. The ambulance entrance was adjacent to the trauma room.

A review of P#1's medical record revealed that he arrived at the facility's ED at 3:20 a.m. on 4/10/2021. Continued review of the record revealed that P#1's mother signed an acknowledgement of receipt of Patient Rights and Responsibilities at 3:33 a.m. Physician (MD) CC initiated the medical screening examination (MSE) at 3:30 a.m. A review of the MSE revealed that P#1's chief complaint was auditory hallucinations (hearing voices that were not there). P#1 denied having suicidal ideations (SI) (thoughts of harming self) or homicidal ideations (HI) (thoughts of harming others). P#1 denied that the hallucinations were commanding (instructing or demanding) and denied visual hallucinations. Continued review of the MSE revealed that P#1 denied additional medical concerns. P#1 informed MD CC that he heard voices in the past and acknowledged recent methamphetamine (illegal stimulant) use. MD CC performed a physical examination of P#1 that revealed P#1 was alert and oriented, cooperative and in no apparent distress. P#1's speech was normal, his affect was normal, judgement was normal, thought content was normal and cognitive function was normal. MD CC documented that P#1 did not have acute SI or HI and showed no signs of organic pathology (physical changes). At 3:35 a.m., MD CC ordered Lorazepam (Ativan) (used for anxiety) for P#1. MD CC documented a clinical impression of methamphetamine abuse and drug induced auditory hallucinations.

RN AA initiated the triage assessment at 3:39 a.m. P#1 reported that he started hearing voices about ten hours after using methamphetamines. P#1 denied suicidal ideations or homicidal ideations. P#1 denied using alcohol or other drug use. P#1 was assigned a triage level of 3.

A review of the Emergency Notes written at 3:45 a.m. by RN BB revealed that P#1 was not in ED room 8. RN BB documented that P#1 had not informed the staff that he was leaving. RN BB was unable to discuss the risks and benefits of treatment or have P#1 sign an AMA form. P#1 was discharged from the ED tracker with a disposition of AMA (against medical advice) at 3:55 a.m.

Review of the Medical Staff Bylaws, Policies, and Rules and Regulations, approved by the Medical Executive Committee on 10/8/2019, General Medical Staff on 11/20/2020, and the Board of Trustees on 12/10/2020 revealed the following:
ARTICLE X
EMERGENCY SERVICES
10.1 General - Emergency services and care will be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care.
10.2 Medical Screening Exams (MSE) - within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition (EMC). Qualified medical personnel (QMP) who can perform the MSE are defined as:
a) ED:
1. Members of the Medical Staff with clinical privileges in Emergency Medicine;
2. Other Active Staff members; and
3. Appropriately credentialed allied health professionals.

A review of the facility's policy, number 9524841, titled 'EMTALA- Georgia Medical Screening Examination and Stabilization Policy', last approved 03/2021, revealed that the purpose of the policy was to require, in conjunction with state specific policies, that an acute care or specialty hospital with an ED provide an appropriate medical screening examination (MSE) and any necessary stabilization treatment to an individual, including every infant born alive, at any stage of development, that came to the ED and requested such examination, as required by EMTALA and all Federal Regulations and interpretive guidelines thereafter. Continued review of the policy revealed that a hospital with an ED provided any individual and every infant who came to the ED, an appropriate MSE within the capabilities of the ED, including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition (EMC) existed, regardless of the individuals ability to pay. The EMTALA obligations were triggered when there had been a request for medical care by an individual within a dedicated emergency department (DED), or when a prudent layperson would recognize that an individual on hospital property required emergency care or examination, though no request for treatment was made. If an EMC was determined to exist, the hospital provided either (1) further medical examination and necessary stabilization within the capabilities of the staff and facilities available at the hospital or (2) an appropriate transfer to another medical facility. The CEO of the hospital, the executive officer responsible for the ED and the ED Director were responsible for implementation of the EMTALA policies outlined herein.

Definitions included but were not limited to:

Emergency Medical Condition (EMC) meant a medical condition that manifested itself by acute symptoms of enough severity (including severe pain, psychiatric disturbances or symptoms) such that in the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual in serious jeopardy
b. Serious impairment to bodily functions
c. Serious dysfunction of any bodily organ or part
d. With respect to a pregnant woman who was having contractions
g. With respect to an individual with psychiatric symptoms;
h. That acute psychiatric or acute substance abuse symptoms were manifested; or
i. That the individual expressed suicidal or homicidal thoughts or gestures and was determined to be a danger to self or others.

Medical Screening Examination (MSE) was the process required to reach with reasonable clinical confidence, the point at which it was determined whether an EMC existed. Screening was conducted to the extent necessary, by physician's and/or other QMP to determine whether an EMC existed. With respect to an individual with behavioral symptoms, and MSE consisted of both a medical and behavioral health screening.

General requirements included: any hospital with an emergency department will provide to any individual who "comes to the emergency department" an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an EMC exists, regardless of the individual's ability to pay when a request is made by or on behalf of the individual for medical care, or a prudent layperson would observe that such care is needed, whether the individual is in the hospital's DED or elsewhere on the hospital's campus. EMTALA required the hospital to do the following:
Provide an appropriate MSE to the individual within the capability of the hospital's emergency department to determine whether an EMC existed.

Leaving DED after the MSE. For those individuals that indicated a desire to leave the DED against medical advice ("AMA") after receiving an MSE, the facility used its best efforts to:
-Complete the registration process and open a medical record;
-Offer the individual further medical examination and treatment as may be required to identify and stabilize an EMC;
-Log the individual in the Central Log;
-Discuss with the individual the risks and benefits involved in leaving against medical advice and document same;
-Take all reasonable steps to secure the individual's written informed consent to refuse or withdraw from such examination and treatment by having the individual sign the AMA Form, if possible;
-Describe, in the medical record, the examination and treatment that was refused or the request for treatment was withdrawn; and
-Sign, date and time the entry.

During the ED tour on 4/19/2021, an interview was conducted with Registrar EE at 1:20 p.m. at the registration desk. Registrar EE explained that when a patient presented to the ED, registration was limited to the patient's social security number, name, date of birth and chief complaint. She added if a patient's chief complaint was suicidal ideations, the triage nurse was notified. The patient was triaged and taken to a room. If a patient wanted to leave the ED, she attempted to get the patient to stay and talk with the provider. If the patient again refused, she would have the patient sign the Against Medical Advice (AMA) form.

During an interview with Registered Nurse (RN) BB on 4/19/2021 at 2:30 p.m. in the Azalea room, she stated she had worked in the facility's ED for two years. She confirmed that she was P#1's primary nurse. RN BB recalled that she received report from RN AA. RN BB noted that Lorazepam was ordered for P#1. RN BB went to prepare the ordered Lorazepam. When RN BB went into ED room 8, the only person in the room was P#1's mother. RN BB recalled that P#1's mother was upset and yelling and did not provide information about P#1's location. RN BB said that ED staff informed her that P#1 was "out by the road up near the red light" and security was trying to get the patient to come back into the ED. RN BB was unaware if the police were notified. RN BB explained that MD CC performed the MSE while P#1 was in triage, and she did not observe the MSE. RN BB explained that if there was no 1013 (Georgia's legal form that allows a patient to be held involuntarily when the patient is a threat to self or others) order, then a sitter was not provided. RN BB confirmed that P#1 did not have an order for a 1013, and RN AA reported that P#1 denied suicidal or homicidal ideations. When asked about the facility's general practice regarding patients' being placed in an ED Behavioral Health room, RN BB explained that patients were not placed in those rooms unless they had 1013.

During an interview with RN AA on 4/19/2021 at 2:55 p.m. in the Azalea room, he stated he had worked in the facility's ED for two years and had been a nurse for 12 years. RN AA confirmed that he was the triage nurse on 4/10/2020 when P#1 presented to the ED. RN AA explained that P#1 reported using methamphetamine several hours earlier and hearing voices. P#1 reported that he had similar symptoms previously after using methamphetamines. RN AA completed the suicide risk assessment and P#1 denied having any suicidal or homicidal ideations. RN AA recalled that MD CC came into triage and evaluated P#1 while P#1's family member remained in the waiting room. RN AA said P#1 was alert and aware that he was hearing voices, which was his only complaint. RN AA said he escorted P#1 to ED room 8 and he did not see him again. RN AA said that if a patient were suicidal or homicidal, they were placed in an ED Behavioral Health room, even if they were not a 1013.

During an interview with ED Physician (MD) CC on 4/19/2021 at 3:15 p.m. in the Azalea room, he confirmed that he remembered P#1. MD CC completed P#1's exam in the triage area. MD CC said P#1 reported recently used methamphetamine and heard voices. MD CC explained that P#1 was cooperative, a little 'antsy' and verbalized that he did not want to be here but his mother brought him into the ED. MD CC recalled that P#1 requested that he wanted medication to help him calm down because it helped in the past. MD CC said P#1's family member was not present during the evaluation. MD CC said he did not make P#1 a 1013 because the patient was not a threat to self or others, and P#1 was a nice, pleasant guy that reported hearing voices.

MD CC ordered Lorazepam for P#1 and prepared his discharge orders/instructions. MD CC learned from staff that P#1 left prior to receiving the medication. MD CC said he had not seen P#1 leave. MD CC explained psychiatric patients were evaluated in triage in case a 1013 order is required. After triage, patients are assigned an ED Behavioral Health bed as soon as possible.

The hospital failed to appropriately monitor Patient #1 enabling him to leave, delaying an appropriate continuing medical screening exam. The risks and benefits of leaving were not discussed, and his decision-making capacity was not assessed. Patient #1 was agitated and the physician wrote an order for Ativan to be administered.

Based on review of the 4/10/2021 video recording, review of medical records, review of facility policy and procedures and interviews, it was determined that the facility failed to provide stabilizing treatment for one of 20 patients (Patient #1) when Patient #1 presented to the Emergency Department (ED) on 4/10/2021 for treatment of 'hearing voices'. P#1 was left unmonitored in an ED room and left the ED without notifying the staff.

Findings:

A review of the ED video recordings for P#1 revealed the following:
First video: On 4/10/2021 (no time stamp), P#1 walked into the ED entrance alone and went to the registration desk. Per the time elapsed on the video recording, two minutes later a female family member entered, spoke with P#1 and sat down in the waiting room. RN AA spoke with P#1 at the registration desk and escorted him into triage room 1.
Second video: On 4/10/2021 (no time stamp) RN AA escorted P#1 to ED room 8. Per the time elapsed on the video recording, approximately one to two minutes later, RN AA exited ED room 8. At video elapsed time of 10 minutes 30 seconds, P#1's female family member entered ED room 8. At video elapsed time 13 minutes 15 seconds, a security officer walked down the hall. At video elapsed time 16 minutes 30 seconds, P#1's female family member exited ED room 8 and walked to the nurses' station across from ED room 8 and spoke with an unidentified nurse. A female family member paced in and out of ED room 8 at video elapsed time 17 minutes 30 seconds. At video elapsed time 17 minutes 50 seconds, P#1 exited ED room 8 and paced from the hallway to ED room 8 doorway continuously until he walked out of camera view at video elapsed time 20 minutes 52 seconds.
Third video: On 4/10/2021 (no time stamp) numerous staff members observed moving in and out of the trauma room. RN BB and other staff members are seen at the desk. At video elapsed time 2 minutes 30 seconds, P#1 walked down hallway and exited out the ambulance entrance. The ambulance entrance was adjacent to the trauma room.

A review of P#1's medical record revealed that he arrived at the facility's ED at 3:20 a.m. on 4/10/2021. Continued review of the record revealed that P#1's mother signed an acknowledgement of receipt of Patient Rights and Responsibilities at 3:33 a.m. Physician (MD) CC initiated the medical screening examination (MSE) at 3:30 a.m. A review of the MSE revealed that P#1's chief complaint was auditory hallucinations (hearing voices that were not there). P#1 denied having suicidal ideations (SI) (thoughts of harming self) or homicidal ideations (HI) (thoughts of harming others). P#1 denied that the hallucinations were commanding (instructing or demanding) and denied visual hallucinations. Continued review of the MSE revealed that P#1 denied additional medical concerns. P#1 informed MD CC that he heard voices in the past and acknowledged recent methamphetamine (illegal stimulant) use. MD CC performed a physical examination of P#1 that revealed P#1 was alert and oriented, cooperative and in no apparent distress. P#1's speech was normal, his affect was normal, judgement was normal, thought content was normal and cognitive function was normal. MD CC documented that P#1 did not have acute SI or HI and showed no signs of organic pathology (physical changes). At 3:35 a.m., MD CC ordered Lorazepam (used for anxiety) for P#1. MD CC documented a clinical impression of methamphetamine abuse and drug induced auditory hallucinations.

RN AA initiated the triage assessment at 3:39 a.m. P#1 reported that he started hearing voices about ten hours after using methamphetamines. P#1 denied suicidal ideations or homicidal ideations. P#1 denied using alcohol or other drug use. P#1 was assigned a triage level of 3.

A review of the Emergency Notes written at 3:45 a.m. by RN BB revealed that P#1 was not in ED room 8. RN BB documented that P#1 had not informed the staff that he was leaving. RN BB was unable to discuss the risks and benefits of treatment or have P#1 sign an AMA form. P#1 was discharged from the ED tracker with a disposition of AMA (against medical advice) at 3:55 a.m.

A review of the facility's policy, number 9524841, titled 'EMTALA- Georgia Medical Screening Examination and Stabilization Policy', last approved 03/2021, revealed that the purpose of the policy was to require, in conjunction with state specific policies, that an acute care or specialty hospital with an ED provide an appropriate medical screening examination (MSE) and any necessary stabilization treatment to an individual, including every infant born alive, at any stage of development, that came to the ED and requested such examination, as required by EMTALA and all Federal Regulations and interpretive guidelines thereafter. The EMTALA obligations were triggered when there had been a request for medical care by an individual within a dedicated emergency department (DED), or when a prudent layperson would recognize that an individual on hospital property required emergency care or examination, though no request for treatment was made. If an EMC was determined to exist, the hospital provided either (1) further medical examination and necessary stabilization within the capabilities of the staff and facilities available at the hospital or (2) an appropriate transfer to another medical facility.

Definitions included but were not limited to:

Emergency Medical Condition (EMC) meant a medical condition that manifested itself by acute symptoms of enough severity (including severe pain, psychiatric disturbances, or symptoms) such that in the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual in serious jeopardy
b. Serious impairment to bodily functions
c. Serious dysfunction of any bodily organ or part
d. With respect to a pregnant woman who was having contractions
e. That there was inadequate time to effect a safe transfer to another hospital before delivery; or
f. That transfer may pose a threat to the health and safety of the woman or the unborn child; or
g. With respect to an individual with psychiatric symptoms;
h. That acute psychiatric or acute substance abuse symptoms were manifested; or
i. That the individual expressed suicidal or homicidal thoughts or gestures and was determined to be a danger to self or others.

Leaving DED after the MSE. For those individuals that indicated a desire to leave the DED against medical advice ("AMA") after receiving an MSE, the facility used its best efforts to:
-Complete the registration process and open a medical record;
-Offer the individual further medical examination and treatment as may be required to identify and stabilize an EMC;
-Log the individual in the Central Log;
-Discuss with the individual the risks and benefits involved in leaving against medical advice and document same;
-Take all reasonable steps to secure the individual's written informed consent to refuse or withdraw from such examination and treatment by having the individual sign the AMA Form, if possible;
-Describe, in the medical record, the examination and treatment that was refused or the request for treatment was withdrawn; and
-Sign, date, and time the entry.

A review of the facility's policy titled, 'Psychiatric Referral Plan', no date, revealed that the purpose was to provide a policy and procedure for the coordination of hospital services with the identified needs of the patient population served. It was the policy of the facility to provide hospital services based on identified needs of the patient. Since psychiatric services were not provided at this hospital, suicidal, emotionally ill, alcohol abuse, and drug abuse patients were referred for treatment once they are deemed medically stable. It was the duty of the primary nurse to report to the physician signs of emotional illness, alcohol abuse, or drug abuse when they are observed. The status of the patient must be determined, and observation of the patient must be constant as deemed by the physician. Restraints may be used according to hospital policy only if other methods of control fail. Observation for possible suicide attempts were made and the suicide precaution policy should be followed. The physician may utilize Social Services for assistance in making inpatient/outpatient referrals as deemed necessary. Patients may be referred to Psychologist/Psychiatrist for evaluation and assistance with transfer to Psychiatric facility. Referrals may be made for outpatients to private psychiatrists or psychologists or to community agencies for counseling or inpatient facilities.
If the patient was able to function on his/her own behalf, he/she may make a voluntary commitment to whichever type of hospital the doctor recommends. For those patients who are not able to function on their own behalf, an involuntary commitment to a psychiatric hospital was done. If an involuntary commitment is made, one doctor must certify that the patient is in need of commitment and must go through appropriate legal channels. All involuntary commitments will be followed by completion of a 1013 form and transfer for follow up as accepted by an appropriate psychiatric facility. Family members may or may not be involved. Emergency Department patients that have a psychiatric condition may be referred for a psychiatric consultation as ordered by the Emergency Department physician. The physician will make the final decision as to the disposition of the patient.

During the ED tour on 4/19/2021, an interview was conducted with Registrar EE at 1:20 p.m. at the registration desk. Registrar EE explained that when a patient presented to the ED, registration was limited to the patient's social security number, name, date of birth and chief complaint. She added if a patient's chief complaint was suicidal ideations, the triage nurse was notified. The patient was triaged and taken to a room. If a patient wanted to leave the ED, she attempted to get the patient to stay and talk with the provider. If the patient again refused, she would have the patient sign the Against Medical Advice (AMA) form.

During an interview with Registered Nurse (RN) BB on 4/19/2021 at 2:30 p.m. in the Azalea room, she stated she had worked in the facility's ED for two years. She confirmed that she was P#1's primary nurse. RN BB recalled that she received report from RN AA.
RN BB noted that Lorazepam was ordered for P#1. RN BB went to prepare the ordered Lorazepam. When RN BB went into ED room 8, the only person in the room was P#1's mother. RN BB recalled that P#1's mother was upset and yelling and did not provide information about P#1's location. RN BB said that ED staff informed her that P#1 was "out by the road up near the red light" and security was trying to get the patient to come back into the ED. RN BB was unaware if the police were notified. RN BB explained that MD CC performed the MSE while P#1 was in triage, and she did not observe the MSE. RN BB explained that if there was no 1013 (Georgia's legal form that allows a patient to be held involuntarily when the patient is a threat to self or others) order, then a sitter was not provided. RN BB confirmed that P#1 did not have an order for a 1013, and RN AA reported that P#1 denied suicidal or homicidal ideations. When asked about the facility's general practice regarding patients' being placed in an ED Behavioral Health room, RN BB explained that patients were not placed in those rooms unless they had 1013. RN BB confirmed that she received EMTALA training upon hire and annually thereafter. Crisis Prevention Intervention training was required every 2 years.

During an interview with RN AA on 4/19/2021 at 2:55 p.m. in the Azalea room, he stated he had worked in the facility's ED for two years and had been a nurse for 12 years. RN AA confirmed that he was the triage nurse on 4/10/2020 when P#1 presented to the ED. RN AA explained that P#1 reported using methamphetamine several hours earlier and hearing voices. P#1 reported that he had similar symptoms previously after using methamphetamines. RN AA completed the suicide risk assessment and P#1 denied having any suicidal or homicidal ideations. RN AA recalled that MD CC came into triage and evaluated P#1 while P#1's family member remained in the waiting room. RN AA said P#1 was alert and aware that he was hearing voices, which was his only complaint. RN AA said he escorted P#1 to ED room 8 and he did not see him again. RN AA said that if a patient were suicidal or homicidal, they were placed in an ED Behavioral Health room, even if they were not a 1013. RN AA confirmed that he had completed annual EMTALA training.

During an interview with ED Physician (MD) CC on 4/19/2021 at 3:15 p.m. in the Azalea room, he confirmed that he remembered P#1. MD CC completed P#1's exam in the triage area. MD CC said P#1 reported recently used methamphetamine and heard voices. MD CC explained that P#1 was cooperative, a little 'antsy' and verbalized that he did not want to be here but his mother brought him into the ED. MD CC recalled that P#1 requested that he wanted medication to help him calm down because it helped in the past. MD CC said P#1's family member was not present during the evaluation. MD CC said he did not make P#1 a 1013 because the patient was not a threat to self or others, and P#1 was a nice, pleasant guy that reported hearing voices.

MD CC ordered Lorazepam for P#1 and prepared his discharge orders/instructions. MD CC learned from staff that P#1 left prior to receiving the medication. MD CC said he had not seen P#1 leave. MD CC explained psychiatric patients were evaluated in triage in case a 1013 order is required. After triage, patients are assigned an ED Behavioral Health bed as soon as possible.

Patient #1 was hearing voices and was agitated for which the physician ordered Ativan to be administered. Patient # 1 was not monitored closely enough and was able to leave without having his condition stabilized.