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Based on a review of the facility's central log, medical record, Medical Staff Bylaws, policy and procedures, and staff interviews, it was determined that the facility failed to provide one patient P (#1) out of 20 sampled patients with an appropriate Medical Screening Examination (MSE) within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department (ED), to determine whether or not an emergency medical condition exists for Patient #1 out of 20 sampled emergency medical records reviewed. Specifically, P#1 was accompanied by law enforcement to the facility's ED. Law enforcement requested that a 1013 be signed for the patient. The physician declined to sign a 1013 and did not conduct an MSE. Law enforcement transported P#1 to another hospital ED.

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 (MSE).

Based on a review of the facility's central log, medical record, Medical Staff Bylaws, policy and procedures, and staff interviews, it was determined that the facility failed to provide one patient P (#1) out of 20 sampled patients with an appropriate Medical Screening Examination (MSE) within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department (ED), to determine whether or not an emergency medical condition exists for Patient #1 out of 20 sampled emergency medical records reviewed. Specifically, P#1 was accompanied by law enforcement to the facility's ED. Law enforcement requested that a 1013 be signed for the patient. The physician declined to sign a 1013 and did not conduct an MSE. Law enforcement transported P#1 to another hospital ED.

Findings included:

A review of the facility's central log from 11/01/22 through 4/18/23 revealed that P#1 presented to the Emergency Department (ED) on 3/6/23 and was registered at 11:46 p.m.

A review of P #1's medical record (MR) from Facility #1 revealed that Emergency Medical Director (MD) AA was asked to evaluate P #1, who was brought into the ED by the county police. A review of the provider notes revealed "No chief complaint on file." MD AA documented, per the charge nurse, that P#1 was violent and combative, requiring two police officers and facility security to restrain him. MD AA stated in his notes that the county police had requested that he place P#1 on a 1013 (involuntary hold for psychiatric evaluation). MD AA informed officers of his observations and that P#1 did not meet the criteria for a 1013 or inpatient psychiatric treatment. P #1 was discharged to police custody at 11:54 p.m. Further review of the MR failed to reveal a medical screening examination (MSE) for P#1. There was no documentation in the medical record to indicate the patient was triaged and no vital signs were taken upon his presentation to the ED.

A review of P#1's MR from Facility #2 revealed that P#1 presented to the ED on 3/7/23 at 1:21 a.m. escorted by law enforcement. The chief complaint was violent behavior. P#1 was triaged with an ESI two (2) (Emergency Severity Index) (acuity resource with level one (1), most urgent requiring lifesaving intervention, to a level five (5), least urgent). On physical examination, P #1 was described as agitated, exhibiting psychotic behavior, and unwilling to answer questions. In addition, P#1 repetitively said things that made no sense. Physician notes revealed that due to P #1's presentation, P#1 was signed to a 1013 pending medical and psychiatric evaluation.

On 3/8/23 at 1:00 p.m. P#1 was discharged home in stable condition with instructions and outpatient follow up.

A review of "Medical Staff Bylaws, Policies Rules, and Regulations of the facility/Medical Staff Rules and Regulations" for "Emergency Services" revealed that care would be provided to any person who came to the emergency department, as that term was defined in the EMTALA regulations, whenever there were appropriate facilities and qualified personnel available to provide such services or care.

Medical Screening Examination (MSE):
Medical screening examinations, within the capability of the Hospital, would be performed on all individuals who came to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition (EMC). Qualified Medical Personnel (QMP) who could perform medical screening examinations within applicable Hospital policies and procedures were defined as:
(a) Emergency Department
(i) Members of the Medical Staff with clinical privileges in emergency medicine.
(ii) Other Active Staff members; and
(iii) Appropriately credentialed Advanced Practice Professionals
(2) The results of the medical screening examination must be documented before the patient left the ED.

A review of the facility's policy titled "Transfer Activities in Accordance with EMTALA Requirements Policies," policy# 11101630, approved 1/27/22, revealed the purpose of this policy was to establish guidance for providing appropriate medical screening examinations (MSE), stabilizing treatment, and appropriate transfer of patients in accordance with the Emergency Medical Treatment and Labor Act (EMTALA), and all regulations promulgated thereunder.
Further review of the policy stated it is the policy of the Hospital to abide by the requirements set forth in EMTALA regulations for patients presenting to the Hospital seeking emergency treatment by:
1. Providing an appropriate MSE

o Providing necessary stabilizing treatment for emergency medical conditions and labor.
o Providing an appropriate transfer if the hospital does not have the capability or capacity to
provide the treatment necessary to stabilize the emergency medical condition.
o Not delaying examination and/or treatment in order to inquire about the patient's insurance or
payment status.
o Accepting appropriate transfers of patients with emergency medical conditions if the hospital
has the specialized capabilities not available at the transferring hospital and has the capacity
to treat those individuals.
o Obtaining or attempting to obtain written informed refusal of examination, treatment or
appropriate transfer when/if the patient refuses such action.
o Not taking adverse action against physician or qualified medical personnel who refuses to
transfer a patient with an emergency medical condition or against an employee who reports a
violation of EMTALA requirements.

With respect to an individual requesting examination or treatment for an emergency medical condition (EMC) that the individual was on the Hospital property, at or within 250 yards of the main building, including parking decks/lots, sidewalks and driveways.

Involuntary Status - This EMTALA policy applies equally to patients with psychiatric, drug or alcohol related conditions. Such patients who present to the ED will receive a medical screening examination and if they are found to have an emergency medical condition, they will receive stabilizing treatment within the capabilities and capacity of the hospital. If their condition remains unstable an EMTALA appropriate transfer will be arranged for them. The appropriate involuntary transfer forms (1013; 2013) for general psychiatric referral or for a drug or alcohol referral, must be utilized and completed in addition to the hospital transfer forms. No consent for transfer from the patient is required.

Qualified Medical Person - The qualified medical person who performs the medical screening (as outlined in the Medical Rules and Regulations): In the Emergency Room: A physician, Certified Nurse Practitioner or Physician's Assistant (in conjunction with a physician).

An interview took place with the Emergency Medical Director (MD) AA in the conference room on 4/17/23 at 1:05 p.m. MD AA acknowledged that he was the ED physician when P#1 presented to the ED on 3/6/23 around 11:30 p.m. MD AA explained that P#1 arrived at the ED escorted by the county police. MD AA said when P#1 arrived in the lobby, there were a few police officers that were with the patient. MD AA stated that the police officers asked him to place P#1 on a 1013 status. MD AA stated he asked both P#1 and the officers if P#1 was a threat to himself or others. He said that the officers replied, "No." MD AA explained that P#1 said he was not suicidal. MD AA said he explained to the police officers that he could not place P#1 on a 1013. MD AA said he suspected P#1 was on something such as methamphetamines (a stimulant drug that was highly addictive). MD AA stated because P#1 was suspected of being intoxicated with some drug, P#1 did not qualify as a 1013. MD AA said after he explained to the officers, he could not place P#1 on a 1013, the officers picked P#1 up from the chair and left. MD AA stated he never said he would not treat P#1 but explained to the officers that he would not place P#1 on 1013. When asked if he offered to examine the patient, MD AA replied he did not offer a medical screening exam to the patient.

An interview took place with the ED Registered Nurse (RN) BB in the conference room on 4/18/23 at 9:12 a.m. RN BB stated he was the ED Charge Nurse the night P#1 was brought into the ED. RN BB explained he received a call from the neighboring county police, who asked if they could bring P#1 to the ED. RN BB said shortly after, P#1 arrived handcuffed and escorted by two police officers at the emergency medical service entrance. RN BB said P#1 was very violent with the police and kept stating he did not want to be there. RN BB stated that P#1 was angry and required two officers and other security officers to hold him down. RN BB explained he went to get the doctor (MD AA). RN BB said when MD AA arrived, MD AA asked P#1 if he was suicidal. RN BB said the officers wanted P#1 to be treated at the facility, but they did not stay long. RN BB recalled officers asking for P#1 to be placed on a 1013. RN BB could not remember if MD AA offered the officers to treat the patient. RN BB stated he did not triage P#1.


An interview took place with RN CC on 4/18/23 at 9:30 a.m. in the conference room. RN CC stated he had been an RN for 12 years. RN CC recalled the night P#1 was brought into the ED. RN CC said county police brought in a "very aggressive patient." RN CC said the doctor (MD AA) asked P#1 if he was suicidal or homicidal, and P#1 replied, "No." RN CC said police officers asked the MD AA to place P#1 on 1013, but MD AA refused. RN CC stated that MD AA asked P#1 if he wanted to be treated. RN CC said P#1 said no, and P#1 kept repeating he wanted to go to jail. RN CC said the officers left with P#1, and P#1 did see a provider. When asked about her understanding of EMTALA, RN CC explained that all patients who came to the ED requesting to be treated had to be treated to the point they could admit or transfer the patient.

A telephone interview took place with Campus Safety Officer (SO) DD on 4/18/23 at 9:50 a.m. SO DD stated P#1 arrived at the ED on 3/6/23 at 11:30 p.m. SO DD said he was in the ED when police brought in P#1. SO DD stated P#1 was handcuffed and aggressive with the police. P#1 sat down and was kicking and shouting. SO DD said P#1 did not threaten to hurt anyone. SO DD stated he did not recall MD AA's conversation with P#1 or the officers concerning treatment. SO DD stated it was apparent to him that P#1 was going through something. SO DD said he recalled that MD AA explained to the police officers that P #1 was not suicidal, and the police left with P#1.



The facility failed to ensure that their policies and procedures and Medical Staff bylaws were as evidenced by failing ensure that an appropriate medical screening examination was provided within the capability of hospital's emergency department to include ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for patient #1 who presented to the emergency department with Law Enforcement and a request was made by Law Enforcement on the patient's behalf for a psychiatric evaluation on March 6, 2023.